This document defines seizures and epilepsy and describes different types of seizures. It discusses partial and generalized seizures. Partial seizures are further divided into simple and complex seizures. Generalized seizures include absence, tonic, clonic, tonic-clonic, myoclonic and atonic seizures. Various case examples are provided to illustrate the clinical presentation of different seizure types. Risk factors, causes and classification of seizures are also outlined.

1. CONVULSIVE DISORDERKhiddir bin Nasharuddin 2008202444Adam Safin Bin Abdul Mutti 2008402544Qhasmirabt Abu Hazir 2008409674

2. SEIZURES AND EPILEPSYBy: Qhasmirabt Abu Hazir

3. DEFINITIONSSEIZURES- clinical event in which there is sudden disturbance of neurological fx caused by an abnormal or excessive neuronal dischargeEPILEPSY- recurrent, unprovoked seizures.

4. EPILEPSIES25-30% of these children have other neurological disorder (mental handicap, cerebral palsy)Diagnosed clinically, hence a detailed description of events experienced by patient or an adequate account by a reliable witness is crucialEpilepsy should be viewed as a symptom of an underlying neurological disorder and not as a single entity

5. RISK FACTORSHx of previous seizuresRecent withdrawal of anti-convulsant medicationBrain tumorNeurodegenerative disorderHx of remote neurologic insult ( stroke, intracranial hemorrhage,cerebral palsy, head, trauma,meningitisFamilial hx of seizures

6. CAUSESSEIZURESIDIOPATHIC (70-80%)- No obvious underlying pathologySYMPTOMATIC- With underlying pathologyCRYPTOGENIC- Appears to be symptomatic but pathology cannot be identified

7. CAUSESPERINATAL CONDITIONCerebral malformation

8. Intrauterine infection

9. Hypoxic-ischemic

10. Trauma

11. HemorrhagePOISONINGLead

12. Coccaine

13. Drug toxicity

14. Drug withdrawalCAUSESINFECTIONEncephalitis

15. Meningitis

16. Brain abcessSYSTEMIC DISORDERVasculitis

17. SLE

18. Hypertensive encephalopathy

19. Renal failure

20. Hepatic encephalopathyMETABOLIC CONDITIONHypoglycemia

21. Hypocalcemia

22. Hypomagnesemia

23. Hyponatremia

24. Hypernatremia

25. Reyes syndrome

26. Storage disease

27. Degenerative disorderNEUROCUTANEOUS SYNDROMESTuberous sclerosis

28. Neurofibromatosis

29. Sturge-Weber SyndromeOTHERSTrauma

30. Tumor

31. Febrile

32. Idiopathic

33. familialBeware of non-epileptic eventNon-epileptic events:Syncope - day dreaming

34. Night terrors - delirium

35. Migraine - sleep disorder

36. Tics

37. Shuddering spellsSeizures hxOnset, duration and timePre-ictal and ictal phasePost-ictal phaseFamily hxGrowth and development hx-weakness, sensory deficits, change in vision, behavior, balance and gaitPmh- previous hx of seizures or neurologic abnormalities

38. Precipitating factors:Fever

39. Preceding illness

40. Recent hx of head trauma

41. Possibility of ingestion or recent change in antiepileptic medication

42. Risk factorCLASSIFICATIONCLASSIFICATION OF SEIZURESPARTIALGENERALISED Seizures arise from one or part of one hemisphereSeizures arise from both hemisphere simultaneously

43. PARTIAL SEIZURESSIMPLE- Consciousness preservedPARTIALOriginate focally in cortexCOMPLEX-impaired concsiousnessSECONDARILY GENERALIZED

44. MANIFESTATION OF PARTIAL SEIZURESManifestation will depend on the part of the brain where the discharge originatesTEMPORAL LOBE-the most common-may result in strange warning feelings or aura with smell and taste abnormalities and distortion of sound and shape.-lip smacking, plucking at one’s clothing, and walking in non-purposely manner (automatism)-dejavu-consciouness can be impairedFRONTAL SEIZURESInvolve motor cortex

45. May lead to clonic movement, which may travel proximally

46. Asymmetrical tonic seizures can be seen, which may be bizarre and hyperkinetic and can be mistakenly dismissed as non-epileptic eventsOCCIPITAL SEIZURES-cause distortion of visionPARIETAL LOBE SEIZURES- Cause contralateraldysaesthesias (altered sensation), or distorted body image

47. SITUATION 1"I almost enjoy them. The feeling of déja vu, as if I've lived through this moment and I even know what's going to be said next. Everything seems brighter and more alive." "It is a pressure that starts in my stomach, then rises to my chest and throat. When it reaches my chest, I smell an unpleasant odor of something burnt. At the same time I feel anxious."

48. SIMPLE PARTIAL SEIZUREConsciousness not impaired

49. Clinical symptoms include motor, sensory,psychic or autonomicMOTORChange in muscle activity

50. For example:

51. Jerking of finger or stiffening of part of the body

52. Movement may spread (affect one side or extend to both sides)

53. Weakness affecting speech

54. Coordinated action such as laughter or automatic hand movements (aware or not)SENSORYChange in any of the senses

55. For example:

56. Smell or taste things that aren’t there

57. Hear clicking,ringing or person’s voice when there is no actual sounds

58. Feel sensation of “pins and needle”/numbness

59. Feel floating or spinnig in space

60. Visual hallucination AUTONOMICChanges in the part of the nervous system that automatically controls body fx

61. for example:

62. Strange or unpleasant sensation in stomach, chest,or head

63. Change in heart rate

64. Sweating

65. Goose bumpsPSYCHICChange in thinking,feeling or experiencing things

66. For example:

67. Problem with memory

68. Inability to find right word

69. Trouble in understanding spoken or written language

70. Sudden feeling of emotion like fear,depression or happiness

71. Feeling of dejavu (I’ve been through this)

72. Feeling of jamais vu (this is new to me)SITUATION 2“Micky's spells begin with a warning; he says he's going to have a seizure and usually sits down. If I ask him how he feels, he just says 'I feel it.' Then he makes a funny face, a mixture of surprise and distress. During the seizure he may look at me when I call his name but he never answers. He just stares and makes odd mouth movements, as if he's tasting something. Sometimes he'll grab the arm of the chair and squeeze it. He may also pull at his shirt as though he's picking lint off of it. After a few minutes, when he's coming out of it, he asks a lot of questions. He never remembers his 'warning' or these questions. The seizures make him tired; if he has two in the same day, he often goes to sleep after the second one."

74. COMPLEX PARTIAL SEIZURESCOMPLEX PARTIAL SEIZUREConsciousness impaired

75. Temporal lobe epilepsy is the most common type

76. The patient stops what he or she doing and stare blankly, often making rhythmic smacking movements of the lips or displaying other automatism, such as picking at their clothes

77. After few minutes return consciousness, may initially feel drowsy

78. Aura may present: alterations of mood, memory

79. Complex hallucinations of sound, smell, taste,vision,emotional changes (fear,sexual arousal) or visceral sensation (nausea, epigastric discomfort) may also occur.SITUATION 3The seizures start with a tingling in my right thumb. In seconds, my thumb starts jerking. Soon, my whole right hand is jerking. I have learned that by rubbing and scratching my forearm I can sometimes stop the seizure. Other times the jerking spreads up my arm. When it reaches my shoulder, I pass out and people tell me that my whole body starts to jerk.

80. SECONDARILY GENERALIZED ( “JACKSONIAN” SEIZURES)When partial seizures spread to involve the whole brain and produce generalized tonic-clonic seizures.

81. focal seizure followed by generalised tonic-clonic seizureGENERALISED SEIZURESABSENCETypical

82. atypicalTonic GENERALISED-generalised brain involvementClonicTonic-clonicMinor motorAtonic

83. myoclonicSITUATION 4Junsu, a 7-year-old boy, often "blanks out" anywhere from a few seconds to 20 seconds at a time. During a seizure, Junsu doesn't seem to hear his teacher call his name, he usually blinks repetitively, and his eyes may roll up a bit. During shorter seizures, he just stares. Then he continues on as if nothing happened. Some days Junsu has more than 50 of these spells

84. TYPICAL ABSENCE (4-6 years of age)Brief loss of environmental awareness ( LOC), with an abrupt onset and termination, unaccompanied by motor phenomenona except for some eye fluttering and minor alteration in muscle tone or simple automatism such as head bobbing and lip smacking

85. Can often be precipitated by hyperventilation and lasted for few seconds

86. primary generalised absence/petit mal@Stoppage of activity, staring and alteration of concsiousness and may include automatism

87. TONICSustained contraction or stiffness

88. Generalised increase in muscle toneCLONIC- Rythmic jerking of one limb, one side or all of the body

89. SITUATION 6"These seizures frighten me. They only last a minute or two but it seems like an eternity. I can often tell Jessica's going to have one because she acts cranky and out of sorts. It begins with an unnatural shriek. Then she falls, and every muscle seems to be activated. Her teeth clench. She's pale, and later she turns slightly bluish. Shortly after she falls, her arms and upper body start to jerk, while her legs remain more or less stiff. This is the longest part of the seizure. Finally it stops and she falls into a deep sleep."

90. TONIC-CLONICRhythmical contraction of muscle groups following the tonic phase

91. In the rigid tonic phase, children may fall to the ground, sometimes injuring themselves. They do not breathe and become cyanosed.

92. this is followed by clonic phase, with jerking of the limbs. Breathing is irregular, cyanosis persists and saliva may accummulate in the mouth.

93. There may be biting of tongue and incontinence of urine

94. Lasts from a few second to minutes

95. followed by unconsciousness or deep sleep up to several hours

96. post-ictal confusion or headache and a period of subsequent malaise is commonSITUATION 7"In the morning, I get these 'jumps.' My arms fly up for a second, and I often spill my coffee or drop what I'm holding. Now and then my mouth may shut for a split second. Sometimes I get a few jumps in a row. Once I've been up for a few hours, the jumps stop."

97. MYOCLONICshock/lightning like jerk of part of the body

98. Caused by rapid contraction and relaxation of muscles

99. May involve neck,shoulders and upper arms

100. Usually associated with multiple seizure type

101. non-epileptic myoclonus movement are also seen physiologically in hiccoughs (myoclonus of diaphragm) or on passing through stage ii sleep (sleep myoclonus)SITUATION 8"When Minho has a 'drop' seizure, he falls to the ground and often hits his head and bruises his body. Even if I'm right next to him and prepared, I may not catch him. Even with carpet in the bedroom and mats in the bathroom, he gets hurt."

102. ATONIC SEIZURES @ DROP SEIZURESOften combined with myoclonic jerk followed by transient loss of muscle tone causing a sudden fall to the floor or drop of the head

103. Consciousness is impaired during fall and regain alertness immediately upon striking the floor

104. they only occur in context of epilepsy syndromes with other forms of seizuresummaryEPILEPSY/SEIZURESGENERALIZEDAlways a/w with LOC

105. No warning

106. SymmetricalPARTIALPreceded by aura according to different lobeLaboratory and diagnostic evaluation of seizuresComplete lab evaluation of child with new onset of seizures:FBC

107. Measurement of blood chemistry: glucose,calcium,sodium,potassium,chloride,bicarbonate,BUN, creatinine,magnesium,phosphorus

108. Blood or urine toxicology

109. Csf analysis-LP is not necessarily if the patient is afebrile and has no other neurologic signs or if the history does not suggest meningeal infection or subarachnoid hemorrhage.

110. Brain imaging with CT or MRIINDICATION OF BRAIN IMAGING IN AFEBRILE SEIZURESFirst afebrile seizure episode- to exclude any intracranial pathology ie:hematoma,space-occupying lesion which may lead to seizureComplex seizure disorderSuspected epilepsy

111. EPILEPSY SYNDROME

112. DEFINITIONEPILEPTIC SYNDROMES- complex of signs and symptoms that define a unique epilepsy condition. Syndromes are classified on the basis of seizure type(s), clinical context, EEG features and neuroimaging.Paediatric Protocol for Malaysian Hospitalepilepsies that can grouped together according to age, sex, hx, seizure semiology and EEG pattern.

113. CLASSIFICATIONFor details, can refer Tom Illustrated and Paeds ProtocolEPILEPSY SYNDROMESGENERALISED EPILEPSIESInfantile spasms

114. childhood absence epilepsy

115. Lennox-Gastaut syndrome

116. Juvenile myoclonic epilepsyPARTIAL EPILEPSIESBenign rolandic epilepsy

117. Occipital epilepsyDiagnosing epilepsyDiagnosing epilepsy is a multi-step process, usually involving the following evaluations:Confirmation through patient history, neurological exam, and supporting blood and other clinical tests that the patient has epileptic seizures and not some other type of episode such as fainting, breath-holding (in children), transient ischemic attacks, hypoglycemia, or non-epileptic seizures. Identification of the type of seizure involved. Determination of whether the seizure disorder falls within a recognized syndrome. A clinical evaluation in search of the cause of the epilepsy. Based on all previous findings, selection of the most appropriate therapy.

118. DIFFERENTIAL DIAGNOSIS OF SEIZURES

119. Situation 1Junho could feel it. He was in the middle of an exam and didn't want to make a scene, so he tried to control it. But it was no use. The stress of the exam was getting to him, and the longer he held in his tic, the more he could feel it building up inside him. Finally he had no choice but to let it out. It wasn't as bad as he anticipated — his shoulders jerked slightly and no one seemed to notice.

120. TICUsually a temporary condition (transient tic)Affect 25% of people before the age of 18Sudden, repetitive movement or sound that can be difficult to control.Motor and vocal tics (simple or complex)Shoulder shrugging is one of the most common simple motor tics (nose wrinkling,headtwitching,eyeblinking,lipbiting,kicking,jumping)Vocal tics:coughing,throatclearing,sniffing,hissingCauses: no definite causes (emotional factors like stress)Diagnosis: accidental,no specific test,run test to rule out other condition with similar presentation

121. Situation 2My two-year-old son continually holds his breath, either after hurting himself or when he doesn't get his own way. He went blue today and actually appeared to faint – this only lasted a short time. Following this his lips looked blue for a while and he then slept for half an hour.

122. Breath-holding spellsAn episode in which the child stop breathing and loses consciousness for a short period immediately after a frightening or emotionally upsetting event or a painful experienceUsually triggered by physically or emotionally upsetting eventsUsually begin in the first year of life and peak at the age of 2Cyanotic/blue type or pallid typeFurther diagnostic and evaluation needed if the spells occur often May resolve in later year

123. Situation 3Emily Stevens* is afraid to do the ordinary things most of us take for granted. For years, she has been afraid to drive a car, be active in sports or even walk to the grocery store. Ever since Emily was diagnosed with epilepsy as a child, the constant threat of seizures - with loss of body control and consciousness - has made this 41-year-old woman a prisoner in her own home.As a child, Emily experienced sexual abuse and extreme emotional trauma. As an adult, she again became a victim, but this time of rape. To deal with the horror in her life, Emily learned a long time ago to keep her emotions and feelings to herself.When even large doses of epilepsy medications couldn't stop all her seizures, Emily went to the University of Michigan Epilepsy Clinic. It was not long before Linda Selwa, M.D., medical director of the Adult Neurology Outpatient Clinic, discovered that Emily's problem was not only epilepsy, but a recently discovered condition called pseudoseizures.

124. PSYCHOGENIC NONEPILEPTIC SEIZURES/PSEUDOSEIZUREParoxysmal episodes that resemble and often misdiagnosed as epileptic seizurePNES are psychological (emotional,stress-related) in originDo not result from an abnormal electrical discharge from the brainPNES-commonly misdiagnosed as epilepsy in patient with previous diagnosis of epilepsy that does not respond to drugPsychiatric disorderThe diagnosis requires an inpatient admission where the patient is continuously monitored by both an electroencephalogram (EEG) and video camera

125. Physicians believe pseudoseizures are psychological defense mechanisms induced by stress or episodes of severe emotional trauma. The seizures happen when patients try to avoid or forget the trauma.

126. syncopeterm used to describe the loss of consciousness from temporary disruption of cerebral oxygenationdue to the interruption of blood flow to the brain, and the loss of consciousness usually lasts for less than 30 secondsLay term-faintPatients who complain of dizziness, light-headedness, passing out, and/or blacking out must be questioned carefully.a careful history often can clarify the condition and guide further evaluation and careSyncope is a symptom of either cardiac or hemodynamic dysfunction and not a disease

127. tremoran unintentional, somewhat rhythmic, muscle movement involving to-and-fro movements (oscillations) of one or more parts of the bodymost common of all involuntary movements and can affect the hands, arms, head, face, vocal cords, trunk, and legs.In some people, tremor is a symptom of another neurological disorder. The most common form of tremor, however, occurs in otherwise healthy people

128. Causes and diagnosiscaused by problems in parts of the brain that control muscles throughout the body or in particular areas, such as the handsNeurological disorder ie multiple sclerosis,neurodegenerative diseaseDrugs-amphetamine,psychotic drugAlcohol abuseInheritanceUnknown causesDiagnosis: detailed hx,physicalexamination,brain imaging

129. Management and treatment of epilepsyKhiddir bin Nasharuddin

130. Treatment recommended > 2 episodes (recurrence risk up to 80%Attempt to classify the seizure and epileptic syndromeAdd on the 2nd drug if first drug failedRational combination therapy (usually 2 / max 3 drugs ) i.e combine drug with different MOA and consider their spectrum of efficacy, drug interactions and adverse effectsMonitor drug levelsGive consideration when planned for medication withdrawalPrinciple of anticonvulsants therapy for Epilepsy

131. Depends on the probability of recurrence of seizures if the drugs are discontinued and the risk of subsequent epilepsyThis can be determined by considering the neonatal neurological examination, cause of the seizure and the EEG.Neonatal periodIf neonatal neurological examination become normal, discontinue therapyIf neonatal neurological examination is persistently abnormalConsider aetiology and obtain EEGIn most cases – continue phenobarbitone, discontinue phenytoin and reevaluate in a monthDuration of anticonvulsant therapy

132. One month after dischargeIf neurological examination has become normal, discontinue phenobarbitone over 2 weeksIf neurological examination is persistently abnormal, obtain EEGIf no seizures activity or not overtly paroxysmal on EEG, discontinue phenobarbitone over 2 weeksIf seizure activity is overtly paroxysmal continue phenobarbitone until 3 months of age and reaccess in the same manner

133. Anticonvulsants and Type of Seizures

134. Anticonvulsants and Type of Seizures

135. Side Effects and Serious Toxicity of Anticonvulsants

137. Steven-Johnson Syndrome

138. A severe bullous form of erythemamultiforme also involving mucous membrane. Eye involvement may include conjunctivitis, corneal ulceration and uveitis. Caused by drug sensitivity / infection with morbidity and mortality.

139. BenzodiazepinesInc. in frequency of channel opening produced by GABABinding of GABA to its receptor triggers an opening of a chloride channel which leads to an increase in chloride conductanceInflux of chloride ion causes a small hyperpolarization that moves the postsynaptic potential away from its firing threshold and thus inhibiting the formation of action potentialMechanism of Action of Anticonvulsants Drug

140. DivalproateCombination of sodium valproate and valproic acid which reduced to valproate when reaches GI tractSodium channel blocker, block GABA transaminase and action at T-type Ca+ channelValproate is bound to albuminBeware of teratogenecityPhenytoinBlocks voltage gated sodium channels by selectively bind to the channel in the inactive state and slowing its rate of recoveryBound 90 percent to plasma albuminGyngivial hyperplasia

141. TopiramateBlocks voltage dependant sodium channelsIncrease frequency of chloride channel opening by binding to GABA receptorReduced high voltage calcium currentCarbonic anhydrase inhibitorInduced by phenytoin and carbamezipineCarbamezipineReduces the propagation of abnormal impulses in the brain by blocking sodium channels thereby inhibiting the generation of repetitive action potentials in epileptic focus and preventing Do not prescribed in patient with absence seizures as it may cause an increase in seizures

142. Status epilepticus

143. Status epilepticusTwo or more sequential seizures without full recovery of consciousness between seizures or more than 30 minutes of continuous seizure activityEpilepsy Foundation of AmericaAny seizure lasting > 30 minutes or

144. intermittent seizures, without regaining full consciousness in between for 30 minutes.Paediatric Protocol for Malaysian Hospital

145. However, parents and public are advised to call for emergency assistance when a convulsion continues for more than 5 minutes without signs of stopping.

146. Precipitant of status epilepticus in childrenfever/febrile seizure – leading cause of SEMedication changeUnknownMetabolicCongenitalAnoxiaCns infectionTraumaCerebrovascularEthanol/ drug-relatedtumor

147. About 25% of children presenting with status epilepticus have an acute brain injury such as:Purulent or aseptic meningitis

148. Encephalitis

149. Electrolyte disorder

150. Acute anoxia

151. 20% have hx of brain injury or cengenital malformation

152. 50% no definable etiology- 50% of them associated with fever

153. Other frequent causes-cessation of anticonvulsant medicationAny type of epileptic seizures can progress to status epilepticusSTATUS EPILEPTICUSNON-CONVULSIVECONVULSIVE- Continuous absence seizures and partial status epilepticusGeneralized tonic-clonic seizures

154. Has greatest potential for long-term damageDeath or brain damage from status seizures (as opposed to death from the underlying cause) is most likely to result from:Direct damage to the brain caused by the injury that causes the seizures Stress on the system from repeated generalized tonic clonic seizures Injury from repeated electrical discharge in the brain

155. Convulsive status epilepticus is a medical emergency

156. Algorithm for Status EpilepticusChild with seizuresSeizures > 5 min (impending status epilepticus)At home / in the ambulancePR diazepam (0.2 – 0.5 mg/kg) – max 10 mgEnsureVentilationPerfusion adequate (ABC’s)DEXTROSTIXIn the hospitalObtain IV accessIV diazepam (0.2 mg/kg slow bolus)

157. Seizures 5 – 30 mins (established status epilepticus)IV Diazepam (0.2mg/kg slow bolus)IV phenytoin 20 mg/kg (max 1.25gm)If <2 yr old – consider IV pyridoxine 100 mg bolusEnsureChild not on maintenance phenytoinMonitor blood sugar, electrolytes, blood counts, liver function, blood gasesConsider blood culture, toxicology, neuroimaging, antiepileptic drug levels

158. Early Refractory Status Epilepticus (seizures >10 min after phenytoin)IV Midazolam (0.2 mg/kg bolus)IV Phenobarbitone (20mg/kg)NoteMonitor BP, respirationStart inotropic support, especially if Midazolam/phenobarbitone is givenArrange for ICUSecure airway, prepare to use mechanical ventilationTitrate phenobarbitone to achieve burst suppression pattern on EEGIf seizures persist despite 30mg/kg loading dose of phenobarbitone, contact higher up for discussion

159. FEBRILE CONVULSIONBy : Adam Safin bin Abdul Mutti

160. History (example)…“Raju was just 14 months old. He caught a bad cold from one of the children in the playgroup. He had a fever and runny nose. He was taking a nap when I heard this strange banging sound. I ran into his room, and his whole body was stiff and shaking. The whole thing probably lasted less than 10 minutes. They were the longest 10 minutes of my life. He has never had another one, and doesn't need any seizure medication."

161. Definition“ A seizure associated with fever in the absence of another cause and not due to intracranial infection from meningitis or encephalitis” [ Illustrated Textbook of Paediatrics, 3rd edition].Occur in children between 3 months old and 6 years old.

162. Some information…Occur in 3% of children between the ages of 6 months and 5 years.Has a genetic predisposition; 10% risk if the child has a first-degree relative with febrile seizures.

163. Why it is common in children???Seizure threshold is low in children.Viral infection (predominant causes)  rapid increase in temperature  can’t tolerate well  seizures.

164. Type of febrile seizures

165. How to differentiate meningitis and febrile seizure in children???Sign and symptom of meningitis :Headache.Irritability.Nausea.Photophobia.Nuchal rigidity.Positive Kernig and Brudzinski sign (> than 12 months old child).

166. Continue…There are sign of increase intracranial pressure in meningitis, not in febrile seizure :Bulging fontanelle.Ptosis.Sixth nerve palsy.

167. Recurrent Febrile Seizures30-40% of children will have recurrent febrile fits.Risk factors :Early age of onset (less than 15 months old).Epilepsy in first degree relatives.Febrile fits in first degree relatives.Low degree of fever (less than 40°C) during first febrile fits.Brief duration between onset of fever and initial fits.

168. Why Children Need Admission???Main reason :To exclude intracranial pathology.Fear of recurrent fits.To treat or investigate the cause of fever besides meningitis or encephalitis.To allay parental anxiety, especially those who staying far from hospital.

170. Prognosis Children who developmentally normal at the time of febrile fits will continue to develop normally [ Nelson&Ellenberg, Verity et al]There was no difference in children between those experiencing simple seizures and complex seizures.

171. Management and treatment of febrile convulsion

172. Call for helpEvaluate and Resuscitate Glasgow coma scaleAdmit to wardNot all children are admitted to wardInvestigation (lumbar puncture)Must be done ifSign of intracranial infectionPrior antibiotic therapyPersistent lethargy and not fully interactive 6 hours after seizuresStrongly recommended if Age < 12 monthsFirst complex febrile convulsionIn district hospital without paediatricianPatient have a problem bringing the child in again if deterioration at homeFebrile Convulsion

173. Control FeverTake of cloth and tepid spongingAntipyretic Monitor the patient conditionVital signsCounseled parents regarding the benign nature of the diseaseAdvised parents on first aid measures during a convulsionDo not panicLoosen child cloth especially around neckPlace child on left lateral position with head lower than bodyWipe out any vomitusDon’t insert any object or drugStay near the child

174. Rectal diazepamFor parents whose children have high risk of recurrence febrile convulsionConvulsion last more than 5 minutesPrevention of recurrent febrile convulsionsAnticonvulsants are not recommended for prevention of recurrent febrile convulsions