1. convulsions in
children
Prepared by:
ANCY ANTO
M.Sc. Nursing

2. History...
 3000 yrs ago ......Babylonians wrote
about the symptoms and causes of
epilepsy
 caused by demons attacking the person
 The word epilepsy is derived from the
Greek word for "attack’’

3. Patron of epilepsy.........

 St.valentine

4. World epilepsy day
National epilepsy day
November 17

5. Did you know that:
 Epilepsy is not a form of mental illness
 Epilepsy can begin at any age from birth to
99+
 Epilepsy can & does affect memory and
learning.
 NOTHING should be put in the mouth of a
person having a seizure

6.  Medication does not stop all seizures .
 Epilepsy is not contagious
 The tongue cannot be swallowed during a
seizure
 Most seizures are not medical emergencies

7. Seizures...
 It is a transient occurrence of signs and / or
symptoms resulting from abnormal excessive or
synchronous neuronal activity in the brain
 A sudden paroxysmal electrical discharge from the
CNS resulting in involuntary motor, sensory or
autonomic disturbances with or without alteration
in sensorium

8. Epilepsy....
 Is a disorder of the brain characterised by an
enduring predisposition to generate seizures
& by the neurological cognitive, psychological
& social consequences.

9. Epileptic syndrome..
 Is a disorder that manifests one or more
specific types and a specific age of onset and
a specific prognosis.

10. Disorders mimicking
seizures...
 Jitteriness
 Benign neonatal sleep myoclonus
 Breath holding spells
 Shuddering attacks
 Syncopal attacks
 Night terror
 pseudo seizures

11. Provoked vs. Unprovoked
seizures..
 Provoked = occurs during the course of acute
illness
 Common causes
 Febrile seizures
 Metabolic events (b. sugar <36mg/dl)
 Acute CNS infections
 Drug intoxification
 Head trauma

12. Incidence
 72-80 / 1lak under 9 yrs of age
 46-83 / 1lak under 14 yrs of age
 Prevalence
 Seizure disorders: 360/100,000 (India, Saha
SP 2003).
 350/1lak in India
 Greater in neonatal period

13. Classification of Epileptic
Seizures.
 Partial seizures:
 Simple partial (consciousness retained)
Motor
Sensory
Autonomic
Psychic
 Complex partial (consciousness impaired)
Simple partial, followed by impaired consciousness
Consciousness impaired at onset
 Partial seizures with secondary generalization

14.  Generalized seizures
 Absences
 Typical
 Atypical
 Generalized tonic clonic
 Tonic
 Clonic
 Myoclonic
 Atonic
 Infantile spasms
 Unclassified seizures

15. ILAE classification
Self limited
 Focal
 Generalised
Continuous
Classification of epilepsy syndromes
•Idiopathic-focal & general
•Familial
•Symptomatic
•reflex

16. Common causes
Infection to the central nervous system
1. Acquired bacterial meningitis
 tuberculus meningitis
 aseptic
 encephalitis
 cerebral malaria
2. Intrauterine infections

17. Post infectious or post vaccinal encephalopathy
 Pertussis vaccination
 Pan encephalitis
 Post measles encephalopathy
 Chickenpox encephalopathy
 Disseminated encephalomyeolopathy

18. Metabolic causes
 Dehydration
 Dyselectrolytemia
 Acidosis/ alkalosis
 Hypocalcaemia/ hypomagnesaemia
 Inborn errors of metabolism

19. Space occupying lesions in the brain
 Neoplasm
 Brain abscess
 Tuberculoma
 Cysticercosis

20. Vascular
 Arterio venous malformations
 Intracranial thrombosis/ haemorrhage
 Coagulopathies
Congenital malformations
Migration defects

21. Miscellaneous
 Birth trauma
 Birth asphyxia
 Heat stroke
 Brain swelling
 Poisoning
 Lead encephalopathy
 Breath holding spells
 Gray matter degeneration

22. Drugs and poisons
 Toxic doses of phenothiazine
 Salicylate
 Diphenylhydantoin
 Carbon monoxide

23. Causes
Early neonatal
period
Neonatal period 1m - 3 yrs
Birth asphyxia
Obstructed labour
IVH
Hypoglycaemia
IEM
Hypocalcaemia
Kernicterus
Developmental
malformations
Meningitis
Metabolic errors
Febrile
convulsions
Neurologic
infections
Metabolic causes
Lesions
drugs

24. Mechanisms of seizure
1. Underlying aetiology
2. Epileptogenesis
3. Excitability
4. Neuronal injury after prolonged febrile &
afebrile status epilepticus

25. Neuron – action potential

27. Basic mechanisms of
epileptogenesis

28. Neurophysiology and
neurochemistry
Epileptogenic neurons + disinhibition + circuit
PDS trigger Ca channel (Mg)
synchronization
Opens sp. K+ channel
Hyperpolarisation

30. Hyperpolarisation
Disappear depolarisation
seizure

31. Kindling
 Process by which brief trans of electrical
stimuli are repeatedly delivered at
appropriate intervals to a susceptible area of
brain.
 Prolonged generalised seizure

32. Factors determine focal –
generalised
 Excitability of epileptic neurone
 The ease with which the electric discharge
can be propagated from focus
 Threshold of brain stem for disseminating an
electrical discharge

33. Excitatory & inhibitory
neurotransmitters
 Glutamate & aspartate – Excitatory
neurotransmitters
Induces Ca + ion current
Depolarisation
seizure

35. Inhibitory neurotransmitters
GABA Hyperpolarisation
GABA receptors are coupled with Cl- channel
stabilises cell in
resting potential
 Pyridoxine deficiency
 Adenosine- inhibit the release of excitatory
neurotransmitters

36. Catecholamine's &
indolamines
 ↓ in nor epinephrine -↑ seizure susceptibility
 ↑ in nor epinephrine- ↓ seizure severity

37. Biochemical alterations
induced by seizure

38. epilepsy syncope
Precipitating factors
Occurrence
Onset
Duration
Jerking limbs
Facial colour
Perspiration
Post ictal recovery
Post ictal confusion
EEG & prolactin
Rare
Awake , sleep
Abrupt
60-90 sec
Yes
Flushed
Hot, sweaty
Slow
Common
Positive
Common
Awake
Gradual
10-15 sec
Occasional
Pale
Cold, clammy
Rapid
Uncommon
Negative

39. Partial seizures.
 Simple partial
Localised motor symptoms
Somatosensory, psychic, autonomic symptoms
 Manifestations
- aversive seizure- eyes and head turn away
from focus & loss of consciousness
- rolandic seizure - tonic–clonic movements
involving face, salivation, arrested speech

40.  Jacksonian march
- Sequential progression of Clonic movements

42. Simple partial seizures with
sensory signs..
 Numbness
 Tingling
 Pricking
 Paresthesia/ pain originating in one area
 Visual sensations
 Motor phenomena – posturing / hypertonia
- Uncommon < 8yrs

43. Complex partial seizures(psychomotor
seizures)
 3yrs – adolescence
 Characterised by
- Period of altered behaviour
- Amnesia
- Inability to respond to environment
- Impaired consciousness during event
- Drowsiness / sleep
- Confusion & amnesia

44. aura
 odd or pleasant odours
 Auditory or visual hallucinations
 Ill defined feelings (de javu)
 Strong feelings of fear and anxiety
 In small children
- emission of cry
- attempt to run

45. Patterns of motor behaviour
 Stereotypic
 May suddenly cease activity , appear dazed
stare into space
 Confused & apathetic
 Become limp or stiff
 automatisms
 Post ictal confusion

46.  Exhibit oropharyngeal activities –smacking
chewing , drooling etc
 Rarely exhibit – temper tantrums or rage

48. Generalised seizures
 Tonic clonic seizures (grandmal )
- Most common
- Occur without warning
Tonic phase clonic phase post ictal phase

49. Tonic phase
 10- 20 sec
 Eyes roll upward
 Immediate loss of consciousness
 Stiffness
 Contraction of entire body
 Arms flexed
 Legs, head & neck
flexed

50.  May utter a peculiar cry
 Apnoeic
 Increased salivation
 Loss of swallowing reflex
 If standing, falls to floor or ground

51. Clonic phase
 30 sec
 Violent jerking movements
 Foams at mouth
 Incontinent of urine and faeces

52. Post ictal state
 Appears relaxed
 Remain semiconscious
 May awake in few minutes
 Confused for several hours
 Poor coordination
 Mild impairment in fine motor movements

53.  Visual & speech difficulties
 Vomit or complain of severe headache
 Usually sleeps for several hours
 Feels tired
 No recollection of event

54. Absence seizures (petit mal/
lapses)
 4-12 years of age
 common in girls than boys
 Ceases at puberty
 Brief / no loss of consciousness
 No alteration in muscle tone
 May go unrecognised
 Abrupt in onset

55. Manifestations:
 Brief loss of consciousness
 Without aura
 5-10 sec
 Slight loss of muscle tone
 Minor movements
 No incontinence
 Amnesia
 Need reorientation

56. Atonic & akinetic seizures
(drop attacks )
 2-5 yrs
 Sudden momentary loss of muscle tone &
postural control
 Recurrent frequently
Manifestation :
- Loss of tone causing child to fall down

57. Myoclonic seizures
 Seizure episodes
 Sudden brief contractions of a muscle
 No post ictal state
 May / not LOC

58. Infantile spasms
 Infantile myoclonus / massive spasms /
hypsarrhythmia / salaam episodes / Infantile
myoclonic spasms
 6- 8 months of life
 Twice common in boys
 Numerous without post ictal drowsiness

59. Manifestations
 Series of sudden muscular contractons
 Head flexed arms extended & legs drawn up
 Eyes rolling
 Preceded / followed by cry
 May / not LOC
 Flushing / pallor / cyanosis

60.  Jack-knife seizure – sudden dropping forward
of the head & neck with trunk flexed forward
 Single momentary shock like contractions

61. Comparison of simple, complex partial
& absence seizure
Clinical features Simple complex Absence
Age of onset Any age Uncommon before
3 yrs
Uncommon before
3 yrs
Freq /day Variable 1- 2 times Multiple
Duration < 30 sec >60 sec <10 sec
Aura May be sole
manifestation
Frequently never
Impaired
consciousness
Never always Always
Automatisms never frequent frequent

62. Clinical
features
Simple complex Absence
Clonic
movements
Frequent Occasional Occasional
Post ictal
impairment
Rare Frequent Never
Mental
disorientation
Rare Common Unusual

63. Video game related epilepsy
 Flicker frequency of video games
 Type – generalised , simple / complex /
absence
 Treatment – abstain from video games
 Factors – screen brightness, sleep
deprivation, fatigue, fever, short distance
from screen

64. Epilepsy syndromes
 The Major Benign Partial Syndromes
1. Benign Rolandic Epilepsy
- Male preponderance 60%
- Onset 2 - 13 years (peak: 9-10 years)
- Older children- motor & somatosensory
symptoms, usually nocturnal.

65.  Younger children- Hemiclonic / GTCS
(especially at night).
 Rx: None if seizures are mild and rare.
 Most AEDs very effective.
 Evolution: Recovery before 15 - 16 years.

66. Benign Occipital Epilepsy
 Frequency- rare
 Genetic 37%, migraine 17%
 Male = female
 Onset 2 - 17 years (peak:7 - 8 years)

67.  Initial visual symptoms, often followed by a
hemiclonic seizure or by automatism
 Postictal migrainous cephalgia in a quarter of
the cases.
 Rx: Most AEDs with control in 60%.
 Recovery by end of adolescence.

68. The Major Primary Generalized
Syndromes
Childhood Absence Epilepsy (True Petit Mal
Epilepsy)
 Frequency 8%
 Genetic predisposition- strong 20%
 Female preponderance 75%
 Onset 3 - 12 years (peak: 6 - 7 years)
 Very frequent simple absences.

69.  Rx: VPA or ESM with control in 70 - 80%.
Evolution: Remission- 95%.
- Rare persistence of absences only- 6%.
- GTCS during adolescence or later- 40%.

70. Juvenile Myoclonic Epilepsy (JME)
 Frequency 5%
 Genetic predisposition- strong >25%
 Male = female
 Onset: 8-26 years (peak: 16 - 17)
 Myoclonus , GTCS often also occur,
occasionally absence.
 Rx: VPA with control in 60 - 100%
 Evolution: Rarely remits (<10%)

71. Grand Mal on Awakening
(GMA)
 Genetic predisposition- strong >10%
 Male > female
 Onset 6-24 (peak: puberty)
 GTS exclusively or predoninantly (90%)
 Myoclonic or absence may occur.
 Rx: VPA with control in 60 - 100%
 Evolution: Rarely remits (<20%)

72. The Major Secondary
Generalized Syndromes
Infantile Spasms (West Syndrome)
Lennox Gastaut Syndrome (LGS)
 Frequency 3 - 10%
 Genetic predisposition- no
 Male preponderance
 Onset 1 - 8 years (peak: 3 - 5 years)

73.  Poor prognosis in most cases
 Tonic, atypical absence, drop attacks, other
generalized or partial seizures.
 Rx: VPA,rarely with complete control.
 persisting seizures.

74. DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 Laboratory investigations
- Serum glucose & calcium levels
• Lumbar puncture – Ist febrile seizures
protein content – increased

75. Imaging studies:
 CT
 MRI- structural lesions
 PET-demonstrate perfusion,O2 & glucose intake
 SPECT scan- perfusion in ictal & inter ictal state
 Cerebral angiography
 Magneto encephalography
 Telemetry

76. Electroencephalogram
Electric activity of brain.
 Fast activity – beta rhythm(14 - 20 Hz)
 Alpha rhythm – 8 -13 Hz
 Theta rhythm – 4 - 7 Hz
 Slow rhythm- 1 - 3 Hz

80. Absence seizure

81. Abnormalities.
 Slow/ abnormal rhythm-generalised ,localised
or lateralised to one side thus helps to
anatomic lesions
 Spikes
 Sharp waves
 Poly spikes
 Slow waves (hypsarrhythmia)

82. Tests consider in the evaluation of
patients with seizures
Type Test Comments
Simple partial
Complex partial
GTC
Absences
MRI
MRI
MRI
None required
Rule out
structural lesions
Rule out
structural lesions
Rule out
structural lesions

83. Management of child with
seizures
Goals:
1. Ensure adequate vitals & oxygenation
2. Terminate seizure activity
3. Prevent seizure recurrence
4. Establish the diagnosis & treat the
underlying

84. steps
 Step I – confirm diagnosis
 Step II – establish seizure type & syndrome
 Step III – evaluate the need for treatment
 Step IV – select AED
 Step V – start monotherapy (start slow go
slow policy)
 Step VI – switch to another monotherapy
add on therapy

86. Treatment of a newly diagnosed case of
epilepsy
Newly diagnosed case
Ist monotherarpy seizure therapy
IInd monotherapy/ combination therapy seizure
free
Intractable epilepsy
Combination therapy ketogenic diet , VNS

87. Choice of AED
Seizure First line second line
partial CBZ, PHT, SVA , PB OXC, LTG, TPM
2nd gen GTCS SVA, ESM, CZP,
CLB
LTG , TPM , LEV
GTCS SVA, CBZ, PHT, PB TPM, LTG, OXC,
LEV
Absence SVA, CZP, CLB LTG , TPM , LEV
Myoclonic SVA LTG , TPM , LEV
Atonic / tonic SVA CBZ, CLB , NTZ,
LTG, TPM
mixed SVA

90. ILAE GUIDELINE FOR DRUG
LEVEL MONITORING
 Check compliance once or twice YEARLY
 Suspect toxicity after each AED change
DURATION:
 Withdrawal – if seizure free for 2 YEARS
 Gradually over 6-12 wks

91. Ketogenic diet
 A very strict diet that involves fluid restriction,
high fat and low carbohydrate + protein
intake.
 The goal: alter the body’s fuel source from
glucose to fat.
 The basis of the diet – fasting
 The encounter with a faith healer

92.  Duration – 2yrs

93. Sample Meals:
 Meal 1:
 melted butter
 heavy whipping
cream
 chicken
 apple
 sugar free Jell-O

94. Problems that may arise:
 Low blood sugar
 Lethargy
 Nausea
 Vomiting
 Elevated cholesterol
 Kidney stones
 Constipation
 Weight loss or gain
 Dehydration
 Cheating

95. Vagus nerve stimulation
 >12 years
 50% reduction in
seizures

97. Types of surgery
1. Resection
Removal of the area causing the seizures
2. Disconnection
Corpus callosotomy
Multiple subpial transections
3.Hemispherectomy

98. procedure Type
Temporal lobectomy
nonTemporal
lobectomy
Corpus callostomy
Hemispherectomy
Simple/ complex
partial
Partial
Partial, tonic ,clonic
Unilateral , partial ,
hemiparesis

99. Nursing management
 Seizure precautions
 Relieving anxiety
 Managing treatment
 Providing family support & education

100. Febrile seizures
 Occurrence of seizure activity in
neurologically healthy infants & children
between 6 months & 5 yrs of age associated
with fever >38c without evidence of
intracranial infection & with no history of prior
afebrile seizures

101.  Common in 18- 22 months
 Provoked seizures
 Causes:
- Infections of middle ear
- URTI
- Urinary tract & GI infections

102. Types
 Simple febrile seizures:
- 85%
- Generalised seizures
- Lasting less than 15 min
- No post ictal neurologic abnormalities

103.  Complex febrile seizures
- Recurrent within 24 hrs
 Febrile status
- A seizure with duration of 30 min
- Without regaining consciousness interictally

104. Risk factors
 Age <18 months
 Family history
 Shorter duration
Recurrence
75% within 1 yr
Risk of subsequent epilepsy – 2- 2.5 %

105. Diagnostic evaluation
 History
 Serum electrolytes – calcium , magnesium
 Blood glucose
LUMBAR PUNCTURE
 abnormal neurological examination
 Ongoing seizure

106. Management
 During the seizure
- Manage as for any other acute seizure
- Should hospitalise
o Lethargy
o Complex features
o Unclear follow up

108. Long term management
 Primary goal – to prevent recurrences
 Antipyretics – to reduce fever
INTERMITTENT PROPHYLAXIS
 Diazepam – 0.3 – 0.5 mg/ kg orally / rectally
 clobazem - 1mg /kg / day

109. Continuous prophylaxis
 Indications :
- Recurrent complex seizures
- Abnormal neurodevelopment
- Positive family history
 Sodium valproate is preferred

110. Status epilepticus
 A seizure that persists for a sufficient length
of time / is repeated frequently enough that
recovery between attacks does not occur
Early status established status
Epilepticus Epilepticus

111. A condition characterised by an epileptic
seizure that is sufficiently prolonged or
repeated at sufficiently brief intervals so as to
produce an unvarying and enduring epileptic
condition
(dictionary of epilepsy )

112. Etiology
 Recurrent neonatal seizures
 Traumatic subarachnoid haemorrhage
 HIE
 IEM

113. Classification
 Generalised status epilepticus
 Partial status epilepticus
 Refractory status epilepticus
 Super refractory status epilepticus

114. Generalised status epilepticus
 Convulsive seizures
1. Tonic clonic
2. Tonic
3. Clonic
4. Myoclonic
 Non convulsive

115. Refractory status epilepticus
 Persistent seizure beyond 120 min
 Despite of therapy with benzodiazepine,
phenytoin, phenobarbitone or valproate
 Treatment :
- Midazolam
- Thiopentone
- Magnesium
- Ketogenic diet

117. Intractable epilepsy
 It is defined as an at least one seizure every
2 months for the first 5 years of treatment &
subsequently as at least one seizure per year
with failure of at least 3 Ist line AEDs
 Rx: surgery
 Ketogenic diet
 VNS

118. Misconceptions about
childhood epilepsy
 Children with epilepsy are brain injured
 Has mental handicaps
 Only SE will harm child's brain
 An EEG will determine if child has epilepsy
 Abnormal EEG -↑ AED dose

119.  Child has twitches of legs & arms while
asleep. Are these seizures ?
 Blood level AED ↑ - change the dose ?
 AED – only way of treatment
 Surgery – after a attempting all AED
 Life will never be the same

120. Nursing diagnosis
 Risk for injury related to CNS dysfunction &
inability to control self secondary to the type of
seizure.
 Risk for aspiration & ineffective breathing
pattern related to impaired motor activity, LOC.
 Risk for injury related to impaired
consciousness & automatisms

121.  Anxiety / fear related to child having life
threatening seizure activity
 Ineffective tissue perfusion
 Interrupted family processes
 Self esteem disturbances