Course of Pediatrics in the last stage of Medical school in University of Slemani....

1. Presented by: Ali Abdullah
Supervised by: Dr. Aso

2. Definition
Seizure: Is a paroxysmal event due to transient, abnormal, excessive, hyper-
synchronous discharges from an aggregate of CNS neurons; characterized by
disturbance in muscle tone, posture, sensation, consciousness, or
psychological state.
Convulsion: Is seizure with abnormal movement.
Epilepsy: syndrome due to recurrent unprovoked seizures;
it’s diagnosed when there are two or more unprovoked
seizures due to a chronic, underlying process.
Approach: Ideas or actions intended to deal with a problem or situation.
“WordWeb dictionary”

3. ClassificationofSeizure
This is essential for diagnosis, therapy, and prognosis.
 Focal S. Vs. generalized S.
 Febrile S. Vs. non febrile S.
 Epileptic S. Vs. non epileptic S.
 True S. Vs. pseudo S.

4. ClassificationofSeizure

5. ApproachHistory
Examination
Investigation:
early
Acute Rx.:
Non-specific
Acute Rx.:
Specific
Investigation:
further
Long term Rx.

6. Approach
History from and description by an eye witness is the main line of diagnosis.
History of the patient about seizure manifestations may give clue about type and location
of the seizure focus.
Questions:
- Whether, it’s initial onset, or he/she had attacks which was overlooked by the parents?
- Nature and pattern (clustering) of the attack.
- Precipitating factor: (sleep or sleep deprivation, TV, stress, mental activity) or
exacerbations.
- Frequency, duration and time of occurrence.
- History of personality change or symptoms of raised ICP  intracranial tumor; versus
history of cognitive regression  degenerative or metabolic disorder.
- Certain medications such as CNS stimulants and antihistamines.
- History of prenatal and perinatal distress or developmental delay  cong. Or perinatal
brain dysfunction
- Including family history of epilepsy and febrile convulsion.
- History of postictal period.

7. Approach
History :
Age may lead you to the cause or even the type of the seizure:
– Neonate (<1 month): Hypoxia, CNS infection, metabolic, drug
withdrawal, developmental and genetic disorders.
– Infants and children (<12 years): Febrile, genetic, CNS infection,
trauma and idiopathic.
– Adolescent and young adults (13-35): Trauma, alcohol withdrawal,
drugs, tumor, idiopathic.
– Older adults (>35): Cerebrovascular disease (50%), tumor, alcohol
withdrawal, metabolic, Idiopathic.
Abnormal movements:
o Present: Grand-mal, Tonic, Clonic, ...
o Absent: petit-mal, atonic, …
Eye rolling: Absence of eye rolling increase suspicion of non-convulsive causes of LOC.
Duration: significance and even type of the attack.

8. Physical Examination:
General exam includes:
– Vital signs and respiratory and cardiac function.
– Search for signs of infection, trauma, toxins, systemic
illness, neurocutaneous abnormalities, vascular disease
and drugs.
Asymmetries in neurologic exam suggest brain
tumor, stroke, trauma, or other focal lesions.
Skin exam for pigmented or de-pigmented spots .
Approach

9. Investigations:
Laboratory Evaluation:
Blood exam: for CBC, electrolytes, serum glucose,
liver and renal function, urinalysis, toxicology screen
and culture.
Lumbar puncture: indicated if suspicion of CNS
infection (when meningeal signs present),
mandatory in HIV-infected patients.
Approach

10. Acute Management:
A. Non-Specific:
 Admission
 Positioning: Semi prone with head to side to avoid aspiration
 ABC and normalization of vital signs
- Tongue blades should not be forced between clenched teeth
- Oxygen should be given via face mask.
 Blood taken for: RBS, CBC, electrolyte, urea, Cr, lactate,
anticonvulsant level
 Reversible metabolic disorders (suspected or proofed) such as:
(hypoglycemia, hypo/hyper natraemia, hypocalcaemia, drug or
alcohol withdrawal) should be corrected.
Approach

11. Acute Management:
B. Specific: Anticonvulsant therapy
* When to START …?
1. Diazepam 0.2-0.3mg/kg IV slowly; if not responds, repeat after
10 minutes; then if not responds …
2. Phenobarbital or phenytoin 10-20 mg/kg; if not responds, repeat
after 10 minutes; then if not responds …
3. Diazepam infusion, IV medazolam
4. IV Valproic acid
5. GA by pentothal, halothane with muscle relaxant under
ventilator.
C. Further investigations to detect the cause: … …
Approach

12. Approach
Investigations:
• EEG: All patients should have it as soon as possible; Ictal,
postictal abnormality, spikes and waves especially for
epileptic seizures, with provocation by photo stimulation,
sleep induction, hyperventilation. Presence of electrographic
seizure esp. during seizure attacks establish the diagnosis, But
negative EEG does not exclude diagnosis of seizure.
• E.E.G. with simultaneous closed video-recording: can provide
information which rarely records during routine E.E.G.
• Neuro-imaging CT scan & MRI: in unexplained new onset
seizure, but not used routinely.

13. Approach
Differential Diagnosis: Includes a long list, but
the main DDx. are syncope and pseudo-seizure:
1. Breath holding attacks.
2. GERD (sandifire syndrome).
3. Infantile colic.
4. Temper tantrum.
5. Masturbation in female toddlers.
6. Hysterical (conversional disorder).
7. Tics.
8. Others ……

14. Long term therapy includes:
- treatment of underlying condition
- avoidance of precipitating factors
- prophylaxis with antiepileptic therapy
- or surgery,
- and even addressing various psychological and social issues.
Choice of anti epileptic medication based on different factors including:
- Age and sex
- type of seizure
- dosing schedule
- and potential side-effects.
Therapeutic goal:
– complete cessation of seizures
– With minimal side effects
– Using single medication (mono-therapy)
– Dosing schedule that’s easy for the pt. to follow
Approach

15. Start Low, Go Slow
If ineffective, medication should be increased to maximal tolerated
dose based primarily on clinical response rather than serum level.
If unsuccessful, second drug should be added, when control achieved,
the first drug can be slowly tapered.
Some may require poly-therapy
Certain epilepsy syndromes (e.g.: temporal lobe epilepsy) are often
refractory to medical Rx. and benefits from surgical excision of the
epileptic focus.
Approach

16. Selectionofantiepilepticdrugs:

17. Status Epilepticus
Classical definition:
- continuous seizure activity
- or two or more seizures
- in 30 minutes without recovery of consciousness.
Controversial new definition:
- more than 5 minutes of seizure activity
- or two or more seizures without recovery of consciousness.
• Status epilepticus is the most disastrous attack of seizure on the
whole life of the baby if not treated early.
• A neurological emergency with 10-20% mortality
• Treatment protocol of Status epilepticus is crucial even the timings.

18. Status Epilepticus
SE may be Convulsive with tonic/clonic movements or Non-
Convulsive with LOC and often subtle twitching.
Non-Convulsive SE is diagnosed by EEG, and suspected in comatose.
Common causes of childhood SE:
(fever, sub-theraputic anticonvulsant Rx., CNS infection, trauma,
poisoning and metabolic abnormalities)
Investigations:

19. Status Epilepticus
Time bounded algorithm for management of SE; this can be started
once a convulsive seizure has lasted more than 5 minutes:
A. 0-5 minutes: ABC
 Establish IV access.
 Monitor vital signs (esp. pulse oximetry)
 Give 100% Oxygen via mask.
B. 5-15 minutes: Start anticonvulsant
 IV lorazepam (50-100mcg/kg, up to 4mg); Or
 Rectal diazepam (0.5mg/kg, up to 10mg)
 If no response, repeat after 5-10 minutes
C. 15-35 minutes: if persists
 IV phenytoin (15-20mg/kg, rate <1mg/kg/min)
 IV Phenobarbital (15-20mg/kg, rate <1mg/kg/min)

20. Status Epilepticus
D. 45 minutes: Refractory seizure
 IV phenytoin or phenobarbital (whichever was not given)
 Additional phenobarbital (5mg/kg/dose, every 30min. to
maximum of 30mg/kg can be used)
If seizure stops, continue with maintenance phenytoin
(IV/oral/via NG)
Refractory seizure: Intensive care:
 If seizure persists, intensive care should be initiated
 Intubate the trachea and support breathing
 Intensive care medications include midazolam and thiopentone
 EEG monitoring

21. Prognosis
Generally excellent:
• Idiopathic
• Hypocalcemia
• Benign familial neonatal seizure
• Fifth-day fit
Significant risk of adverse neurodevelopmental outcome
• Meningitis
• HIE grade II
• Hypoglycemia
• Cerebral infarction
• Hyper/hypo natremia
• Drug withdrawal
High risk:
• HIE grade III
• Cerebral malformation
• Kernicterus
• Some IEM

22. Prognosis
Prognosis with drug treatment (long term):
By 12 months, 60-70% will be seizure free. After 2
years of seizure-free period, withdrawal of drugs can
be considered.
Predictive factors for relapse:
• Syndromic epilepsy
• Underlying structural pathology
• Severe prolonged epilepsy before remission
• Increased age