2. 1. Identify the key elements in the evaluation of an
individual with seizures.
2. recognize the key features of febrile seizures
3. Recognize the key differences between epileptic
and nonepileptic seizures.
Objectives
7. Seizure:
Paroxysmal involuntary disturbances
of brain function (loss of consciousness
, disturbance of motor. sensory
behavioral. autonomic dysfunction.
What is Epilepsy?
8. Epilepsy is defined as 2 or more unprovoked
afebrile seizures.
(International League Against Epilepsy).
9. What's about seizures occurring during acute
illness e.g. , meningitis or hypocalcaemia ?
10. History is the cornerstone of an accurate
diagnosis
HOW TO DIAGNOSE EPILEPSY
12. Chief complaint analysis/ Associated
symptoms
Detailed description of attack:
GENERALIZED VS FOCAL
FIRST TIME ?, KNOWN CASE OF ?
ONSET/ TIME OF THE DAY/ PROGRESSION
DURATION/ FREQUENCY
CHANGE IN TONE/ COLOR/ BLADDER AND BOWEL
CONTROL/ Tongue bite/ EYE POSITION/ DROOLING AND
FROTHING
13. Chief complaint analysis/ Associated
symptoms
DESCRIPTION OF POST ICTAL STATUS (Todd's
paralysis , postictal dysphasia
Precipitating factor such as fever , acute illness,
emotional or physical or trauma, INGESTIONS
Do the episodes always occur when the child is
upset and crying, during sleep
15. RELEVANT PAST HX
Repeated seizure, use of AED, initial abnormal
EEG,
COMPLIANCE WITH MEDICATIONS/ RECENT
CHANGES/ RECENT WEIGHT CHANGE
Past previous history of meningitis,HIE, head
trauma / IMMUNIZATION
Family history (dominant inheritance )
consanguinity/ SOCIAL HX
Teenager with seizure( suspect drug abuse)
16. Etiology
Any insult to the cerebral cortex can cause seizure(
symptomatic) vs idiopathic / cryptogenic
In future the idiopathic is likely to be smaller group
shifting towards symptomatic group , because
(1) advanced neuroimaging (subtle malformation
dysplastic and migrational disorder
(2) advances in genetic research ( chromosomal
location , and abnormal gene product )
21. 1) simple 2) complex
Simple partial. s.
Motor activity
Preserved consciousness
May have Aura “ headache etc.”
No post ictal phenomenon
EEG
Prognosis excellence
22. 2) Complex
a) Complex partial seizures:
Motor activity
Impaired consciousness
Aura
Difficulty to diagnose in infant + small
children
Automatism common
Infant, alimentary e.g chewing
2ndary generalization
23. Complex
b) Benign COMPLEX partial epilepsy (Rolandic)
Common
Excellent Progresses
Age 9 – 10 years ( resolve before puberty)
Normal Children – unremarkable past history
Normal neurologically
24. b) Benign COMPLEX partial epilepsy (Rolandic)
Family History
Mostly confined to the face ipsilateral limbs
e.g – numbness of the cheek
75% during sleep ( GTC)
Investigation:
EEG: diagnostic
Centrotemporal spikes (Rolandic)
26. 1)Absence seizures:
Sudden cessation (stoppage) of motor activity.
Age of onset 5 years
Never associated with Aura
No postictal state
No loss of body tone
27. 2) Generalized tonic – clonic seizure
Very common
Aura
Eyes roll back
Tonic → clonic movement
Loss of sphincter control
Bite tongue
28. What are the precipitating factors?
1. Fever
2. Fatigue
3. Emotional stress
4. Drug e.g theophylline
37. Clinical manifestation (Typical FS)
Generalized
1 – 10 min (<15 min)
One seizure in the febrile illness
Child is back to normal after the post ictal stage
38. Clinical manifestation (Typical FS)
Fever ( usually caused by URTI, OM)
Controlling the fever does not reduce the risk of seizure
EEG not indicated routinely
risk of Epilepsy 1%(same as general poulation)
39. When EEG indicated?
Atypical F.C
Duration > 15 min
Repeated fit in the same day
Focal seizure
At risk of Epilepsy 5-7%
40. Who are the patient with FC at risk of Epilepsy ?
+ve Family history of Epilepsy
Initial fit started < 9 month:
Atypical seizure
Delayed milestone
CNS abnormality
42. Lumbar puncture should be considered strongly in
infants younger than 12 months
those who have prolonged focal febrile seizures
children who are partially treated with antibiotics
Any age with signs of meningitis
43. 3 % incidence of having a single feb.conv
30 % of them get recurrence of febrile convulsion
30 % got family history of FC
30 % of focal FC present as status epilep.
Role of figure 3 in Febrile convulsion
44. Febrile Convulsion
Treat the cause of the infection
↓ Temp., Drug, Sponging
Reassurance
Prophylaxis not indicated
Oral Diazepam 1 mg/kg/day divided 3 doses for 2 – 3
days. (old), Clobazam (new)
45. Introduction
Definition
Classification
Infantile spasm
Febrile convulsion
Investigation
Status epilepticus
Management
Seizure like disorders
Video
46. What shall we do for the first Afebrile
seizures?
Only simple investigation
Limited role of blood work (? Ca, Glu, Lytes,
Gas)
Afebrile Seizures
55. 5. What other blood tests indicated during
drug therapy.
• CBC 1st 3 months
• LFT
56. What are the indications of blood
monitoring of the anticonvulsant?
57. When to do Drug level?
1. At onset
2. Non compliance
3. At status epilepticus
4. Patient on poly therapy
5. Uncontrolled seizure
6. For? Drug toxicity
7. Hepatic or renal failure
72. Common Causes
1. Febrile seizure (focal)
2. Sudden withdrawal
of anticonvulsant/ non compliance
3. Symptomatic: eg. Structural anomalies
- encephalitis. Etc
- metabolic causes
73. Treatment of status epilepticus
ABCDE
Call for help/ put the patient in the resuscitation
room/ apply universal precautions.
Airway:
– secure and open airway, O2, position/ jaw thrust /
no foreign bodies
Breathing:
– Air entry/ RR/ distress/ O2/ Sat monitor
74. ABCDE
Circulation:
– check pulses/ HR/ BP
– Establish 2 large bore IV lines ( consider IO if no IV
could be obtained after 2 attempts)
– Investigations to send (CBC, electrolytes, Drug
level, ABG,
– Check Blood sugar and correct if hypoglycemic
– If dehydrated or shocky ( 20 ml/kg NS bolus)
75. Disability ( Examine head for trauma, pupils,
consciousness level, focal CNS signs
Exposure ( remove clothes. Temp ( antipyretics if febrile)
/ signs of trauma or bleeding
ABCDE
76. SPECIFIC TREATMENT:
First line Drugs:
Diazepam; 0.1 – 0.3 mg/kg/dose (+ 3 dose)
Lorazepam: 0.05 – 0.1 mg/kg. Less ↓ BP ↓
Respiratory arrest
Midazolam 0.2 – 0.3 mg/kg IM ( better than rectal
diazepam)
82. 1 ) MIGRAINE
if presented with acute neurological events with out significant
headache , particularly those with loss or alteration of
consciousness. ( basilar-type migraine)
post-traumatic migraine : neurological signs occurring after minor
head trauma ( cerebral concussion).
MIGRAINE = headache first
SEIZURES = headache later
83. 2 ) BENIGN PAROXYSMAL VERTIGO BPV
4 years old child manifested by recurrent episodes
of brief disequilibrium , vertigo or dizziness . the child
will grasp nearby persons or furniture for support , last <
1 minute with out loss of consciousness . it recur in
clusters daily for several days then remitting for several
weeks. It is a diagnosis of exclusion. (atonic seizure)
Prognosis is good with out treatment.
84. 3 ) NONEPILEPTIC STARING SPELLS
((PSEUDOABSENCES OR DAY DREAMING))
It occur in children with mental retardation , ADHD,
autism and in normal children.
Made up one-third of those referred for EEG.
must be differentiated from true absence seizures as it
occurred if bored, inactive or in classroom.
Interrupted easily and never associated with automatism
or other motor movement.
hyperventilation might be +ve.
85. 4 ) PSYCHOGENIC NONEPILEPTIC SEIZURES
Abnormal behavior or motor events in a conscious individual
misdiagnosed as epilepsy treated with antiepileptic drugs.
typically in teenagers (11-14 YEARS ) with affective and anxiety
disorder.
high risk in those with a family or a friend history of seizures.
86. 5 ) SYNCOPE
Abrupt loss of consciousness , usually because of a sudden
reduction of a cerebral perfusion.
Mostly are vasovagal in origin.
Distinguished from seizures by the situation in which they
occur. ( emotional, standing, pain )
Pallor with visual changes, and lack of postictal state .
87. 6 ) LONG Q-T SYNDROM
rare life threatening cardiac condition.
present without provocation , mimicking seizures with loss of
consciousness and pallor but lacking postictal state.
((usually find cardiac examination/or ECG
abnormalities))
88. 7 ) BREATH HOLDING SPELLS
Toddlers.
A benign disorder, should be preceded by stimulus then
consistent crying followed by pallor or cyanosis, abnormal
movement ends with regaining level of consciousness.
It never occur without crying, always grow out of it .
89. 8 ) MOVEMENT DISORDERS ( TICS, TREMORS, CHOREA DYSTONIA ,
ATHETOSIS , HEAD BANGING ,k)
Classical motor activity.
Sustained rather than episodic .
No loss of consciousness.
They may coexist with seizures.
RELIEF BY SIMPLE TOUCHING .( GESTE ANTAGONIST )
90. 9) SLEEP DISORDERS ( SLEEP WALKING , NIGHT TERRORS ,
CONFUTIONAL AROUSAL )
It is common for an individual or a family to manifest more than
one of these disturbances.
Sleep walking up to 15% of children, around 6 years, eyes
open, low level of awareness, slow, clumsy ,purposeless.
(( should be differentiated from postictal wandering of night
seizures ))
91. 10 ) SLEEP STARTS ( HYPNIC MYOCLONUS )
A sudden jerking movement upon falling asleep
accompanied by sensation of falling , occurring
at any age and are restricted to sleep usually in
the transitional period between sleep and
wakefulness.
