4. Convulsive disorder


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4. Convulsive disorder

  1. 1. CONVULSIVE DISORDER Khiddir bin Nasharuddin 2008202444 Adam Safin Bin Abdul Mutti 2008402544 Qhasmirabt Abu Hazir 2008409674
  2. 2. SEIZURES AND EPILEPSY By: Qhasmirabt Abu Hazir
  3. 3. DEFINITIONS SEIZURES- clinical event in which there is sudden disturbance of neurological fx caused by an abnormal or excessive neuronal discharge EPILEPSY- recurrent, unprovoked seizures.
  4. 4. EPILEPSIES 25-30% 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 crucial Epilepsy should be viewed as a symptom of an underlying neurological disorder and not as a single entity
  5. 5. RISK FACTORS Hx of previous seizures Recent withdrawal of anti-convulsant medication Brain tumor Neurodegenerative disorder Hx of remote neurologic insult ( stroke, intracranial hemorrhage,cerebral palsy, head, trauma,meningitis Familial hx of seizures
  6. 6. CAUSES SEIZURES IDIOPATHIC (70-80%) - No obvious underlying pathology SYMPTOMATIC - With underlying pathology CRYPTOGENIC - Appears to be symptomatic but pathology cannot be identified
  7. 7. CAUSES PERINATAL CONDITION Cerebral malformation Intrauterine infection Hypoxic-ischemic Trauma Hemorrhage POISONING Lead Coccaine Drug toxicity Drug withdrawal CAUSES INFECTION Encephalitis Meningitis Brain abcess SYSTEMIC DISORDER Vasculitis SLE Hypertensive encephalopathy Renal failure Hepatic encephalopathy METABOLIC CONDITION Hypoglycemia Hypocalcemia Hypomagnesemia Hyponatremia Hypernatremia Reyes syndrome Storage disease Degenerative disorder NEUROCUTANEOUS SYNDROMES Tuberous sclerosis Neurofibromatosis Sturge-Weber Syndrome OTHERS Trauma Tumor Febrile Idiopathic familial
  8. 8. Beware of non-epileptic event Non-epileptic events: Syncope - day dreaming Night terrors - delirium Migraine - sleep disorder Tics Shuddering spells
  9. 9. Seizures hx Onset, duration and time Pre-ictal and ictal phase Post-ictal phase Family hx Growth and development hx-weakness, sensory deficits, change in vision, behavior, balance and gait Pmh- previous hx of seizures or neurologic abnormalities
  10. 10. Precipitating factors: Fever Preceding illness Recent hx of head trauma Possibility of ingestion or recent change in antiepileptic medication Risk factor
  11. 11. CLASSIFICATION CLASSIFICATION OF SEIZURES PARTIAL GENERALISED Seizures arise from one or part of one hemisphere Seizures arise from both hemisphere simultaneously
  12. 12. PARTIAL SEIZURES SIMPLE - Consciousness preserved PARTIAL Originate focally in cortex COMPLEX -impaired concsiousness SECONDARILY GENERALIZED
  13. 13. MANIFESTATION OF PARTIAL SEIZURES Manifestation will depend on the part of the brain where the discharge originates TEMPORAL 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 impaired FRONTAL SEIZURES Involve motor cortex May lead to clonic movement, which may travel proximally Asymmetrical tonic seizures can be seen, which may be bizarre and hyperkinetic and can be mistakenly dismissed as non-epileptic events
  14. 14. OCCIPITAL SEIZURES -cause distortion of vision PARIETAL LOBE SEIZURES - Cause contralateraldysaesthesias (altered sensation), or distorted body image
  15. 15. 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."
  16. 16. SIMPLE PARTIAL SEIZURE Consciousness not impaired Clinical symptoms include motor, sensory,psychic or autonomic
  17. 17. MOTOR Change in muscle activity For example: Jerking of finger or stiffening of part of the body Movement may spread (affect one side or extend to both sides) Weakness affecting speech Coordinated action such as laughter or automatic hand movements (aware or not)
  18. 18. SENSORY Change in any of the senses For example: Smell or taste things that aren’t there Hear clicking,ringing or person’s voice when there is no actual sounds Feel sensation of “pins and needle”/numbness Feel floating or spinnig in space Visual hallucination
  19. 19. AUTONOMIC Changes in the part of the nervous system that automatically controls body fx for example: Strange or unpleasant sensation in stomach, chest,or head Change in heart rate Sweating Goose bumps
  20. 20. PSYCHIC Change in thinking,feeling or experiencing things For example: Problem with memory Inability to find right word Trouble in understanding spoken or written language Sudden feeling of emotion like fear,depression or happiness Feeling of dejavu (I’ve been through this) Feeling of jamais vu (this is new to me)
  21. 21. 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."
  22. 22. COMPLEX PARTIAL SEIZURES COMPLEX PARTIAL SEIZURE Consciousness impaired Temporal lobe epilepsy is the most common type 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 After few minutes return consciousness, may initially feel drowsy Aura may present: alterations of mood, memory Complex hallucinations of sound, smell, taste,vision,emotional changes (fear,sexual arousal) or visceral sensation (nausea, epigastric discomfort) may also occur.
  23. 23. SITUATION 3 The 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.
  24. 24. SECONDARILY GENERALIZED ( “JACKSONIAN” SEIZURES) When partial seizures spread to involve the whole brain and produce generalized tonic-clonic seizures. focal seizure followed by generalised tonic-clonic seizure
  25. 25. GENERALISED SEIZURES ABSENCE Typical atypical Tonic GENERALISED -generalised brain involvement Clonic Tonic-clonic Minor motor Atonic myoclonic
  26. 26. SITUATION 4 Junsu, 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
  27. 27. 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 Can often be precipitated by hyperventilation and lasted for few seconds primary generalised absence/petit mal @ Stoppage of activity, staring and alteration of concsiousness and may include automatism
  28. 28. TONIC Sustained contraction or stiffness Generalised increase in muscle tone CLONIC - Rythmic jerking of one limb, one side or all of the body
  29. 29. 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."
  30. 30. TONIC-CLONIC Rhythmical contraction of muscle groups following the tonic phase In the rigid tonic phase, children may fall to the ground, sometimes injuring themselves. They do not breathe and become cyanosed. this is followed by clonic phase, with jerking of the limbs. Breathing is irregular, cyanosis persists and saliva may accummulate in the mouth. There may be biting of tongue and incontinence of urine Lasts from a few second to minutes followed by unconsciousness or deep sleep up to several hours post-ictal confusion or headache and a period of subsequent malaise is common
  31. 31. SITUATION 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."
  32. 32. MYOCLONIC shock/lightning like jerk of part of the body Caused by rapid contraction and relaxation of muscles May involve neck,shoulders and upper arms Usually associated with multiple seizure type non-epileptic myoclonus movement are also seen physiologically in hiccoughs (myoclonus of diaphragm) or on passing through stage ii sleep (sleep myoclonus)
  33. 33. 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."
  34. 34. ATONIC SEIZURES @ DROP SEIZURES Often combined with myoclonic jerk followed by transient loss of muscle tone causing a sudden fall to the floor or drop of the head Consciousness is impaired during fall and regain alertness immediately upon striking the floor they only occur in context of epilepsy syndromes with other forms of seizure
  35. 35. summary EPILEPSY/SEIZURES GENERALIZED Always a/w with LOC No warning Symmetrical PARTIAL Preceded by aura according to different lobe
  36. 36. Laboratory and diagnostic evaluation of seizures Complete lab evaluation of child with new onset of seizures: FBC Measurement of blood chemistry: glucose,calcium,sodium,potassium,chloride,bicarbonate,BUN, creatinine,magnesium,phosphorus Blood or urine toxicology 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. Brain imaging with CT or MRI
  37. 37. INDICATION OF BRAIN IMAGING IN AFEBRILE SEIZURES First afebrile seizure episode- to exclude any intracranial pathology ie:hematoma,space-occupying lesion which may lead to seizure Complex seizure disorder Suspected epilepsy
  39. 39. DEFINITION EPILEPTIC 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 Hospital epilepsies that can grouped together according to age, sex, hx, seizure semiology and EEG pattern.
  40. 40. CLASSIFICATION For details, can refer Tom Illustrated and Paeds Protocol EPILEPSY SYNDROMES GENERALISED EPILEPSIES Infantile spasms childhood absence epilepsy Lennox-Gastaut syndrome Juvenile myoclonic epilepsy PARTIAL EPILEPSIES Benign rolandic epilepsy Occipital epilepsy
  41. 41. Diagnosing epilepsy Diagnosing 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.
  43. 43. Situation 1 Junho 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.
  44. 44. TIC Usually a temporary condition (transient tic) Affect 25% of people before the age of 18 Sudden, 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,hissing Causes: no definite causes (emotional factors like stress) Diagnosis: accidental,no specific test,run test to rule out other condition with similar presentation
  45. 45. Situation 2 My 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.
  46. 46. Breath-holding spells An 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 experience Usually triggered by physically or emotionally upsetting events Usually begin in the first year of life and peak at the age of 2 Cyanotic/blue type or pallid type Further diagnostic and evaluation needed if the spells occur often May resolve in later year
  47. 47. Situation 3 Emily 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.
  48. 48. PSYCHOGENIC NONEPILEPTIC SEIZURES/PSEUDOSEIZURE Paroxysmal episodes that resemble and often misdiagnosed as epileptic seizure PNES are psychological (emotional,stress-related) in origin Do not result from an abnormal electrical discharge from the brain PNES-commonly misdiagnosed as epilepsy in patient with previous diagnosis of epilepsy that does not respond to drug Psychiatric disorder The diagnosis requires an inpatient admission where the patient is continuously monitored by both an electroencephalogram (EEG) and video camera
  49. 49. 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.
  50. 50. syncope term used to describe the loss of consciousness from temporary disruption of cerebral oxygenation due to the interruption of blood flow to the brain, and the loss of consciousness usually lasts for less than 30 seconds Lay term-faint Patients 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 care Syncope is a symptom of either cardiac or hemodynamic dysfunction and not a disease
  51. 51. tremor an unintentional, somewhat rhythmic, muscle movement involving to-and-fro movements (oscillations) of one or more parts of the body most 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
  52. 52. Causes and diagnosis caused by problems in parts of the brain that control muscles throughout the body or in particular areas, such as the hands Neurological disorder ie multiple sclerosis,neurodegenerative disease Drugs-amphetamine,psychotic drug Alcohol abuse Inheritance Unknown causes Diagnosis: detailed hx,physicalexamination,brain imaging
  53. 53. Management and treatment of epilepsy Khiddir bin Nasharuddin
  54. 54. Treatment recommended > 2 episodes (recurrence risk up to 80% Attempt to classify the seizure and epileptic syndrome Add on the 2nd drug if first drug failed Rational combination therapy (usually 2 / max 3 drugs ) i.e combine drug with different MOA and consider their spectrum of efficacy, drug interactions and adverse effects Monitor drug levels Give consideration when planned for medication withdrawal Principle of anticonvulsants therapy for Epilepsy
  55. 55. Depends on the probability of recurrence of seizures if the drugs are discontinued and the risk of subsequent epilepsy This can be determined by considering the neonatal neurological examination, cause of the seizure and the EEG. Neonatal period If neonatal neurological examination become normal, discontinue therapy If neonatal neurological examination is persistently abnormal Consider aetiology and obtain EEG In most cases – continue phenobarbitone, discontinue phenytoin and reevaluate in a month Duration of anticonvulsant therapy
  56. 56. One month after discharge If neurological examination has become normal, discontinue phenobarbitone over 2 weeks If neurological examination is persistently abnormal, obtain EEG If no seizures activity or not overtly paroxysmal on EEG, discontinue phenobarbitone over 2 weeks If seizure activity is overtly paroxysmal continue phenobarbitone until 3 months of age and reaccess in the same manner
  57. 57. Anticonvulsants and Type of Seizures
  58. 58. Anticonvulsants and Type of Seizures
  59. 59. Side Effects and Serious Toxicity of Anticonvulsants
  60. 60. Steven-Johnson Syndrome
  61. 61. 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.
  62. 62. Benzodiazepines Inc. in frequency of channel opening produced by GABA Binding of GABA to its receptor triggers an opening of a chloride channel which leads to an increase in chloride conductance Influx of chloride ion causes a small hyperpolarization that moves the postsynaptic potential away from its firing threshold and thus inhibiting the formation of action potential Mechanism of Action of Anticonvulsants Drug
  63. 63. Divalproate Combination of sodium valproate and valproic acid which reduced to valproate when reaches GI tract Sodium channel blocker, block GABA transaminase and action at T-type Ca+ channel Valproate is bound to albumin Beware of teratogenecity Phenytoin Blocks voltage gated sodium channels by selectively bind to the channel in the inactive state and slowing its rate of recovery Bound 90 percent to plasma albumin Gyngivial hyperplasia
  64. 64. Topiramate Blocks voltage dependant sodium channels Increase frequency of chloride channel opening by binding to GABA receptor Reduced high voltage calcium current Carbonic anhydrase inhibitor Induced by phenytoin and carbamezipine Carbamezipine Reduces 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
  65. 65. Status epilepticus
  66. 66. Status epilepticus Two or more sequential seizures without full recovery of consciousness between seizures or more than 30 minutes of continuous seizure activity Epilepsy Foundation of America Any seizure lasting > 30 minutes or intermittent seizures, without regaining full consciousness in between for 30 minutes. Paediatric Protocol for Malaysian Hospital
  67. 67. However, parents and public are advised to call for emergency assistance when a convulsion continues for more than 5 minutes without signs of stopping.
  68. 68. Precipitant of status epilepticus in children fever/febrile seizure – leading cause of SE Medication change Unknown Metabolic Congenital Anoxia Cns infection Trauma Cerebrovascular Ethanol/ drug-related tumor
  69. 69. About 25% of children presenting with status epilepticus have an acute brain injury such as: Purulent or aseptic meningitis Encephalitis Electrolyte disorder Acute anoxia 20% have hx of brain injury or cengenital malformation 50% no definable etiology- 50% of them associated with fever Other frequent causes-cessation of anticonvulsant medication
  70. 70. Any type of epileptic seizures can progress to status epilepticus STATUS EPILEPTICUS NON-CONVULSIVE CONVULSIVE - Continuous absence seizures and partial status epilepticus Generalized tonic-clonic seizures Has greatest potential for long-term damage
  71. 71. Death 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
  72. 72. Convulsive status epilepticus is a medical emergency
  73. 73. Algorithm for Status Epilepticus Child with seizures Seizures > 5 min (impending status epilepticus) At home / in the ambulance PR diazepam (0.2 – 0.5 mg/kg) – max 10 mg Ensure Ventilation Perfusion adequate (ABC’s) DEXTROSTIX In the hospital Obtain IV access IV diazepam (0.2 mg/kg slow bolus)
  74. 74. 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 bolus Ensure Child not on maintenance phenytoin Monitor blood sugar, electrolytes, blood counts, liver function, blood gases Consider blood culture, toxicology, neuroimaging, antiepileptic drug levels
  75. 75. Early Refractory Status Epilepticus (seizures >10 min after phenytoin) IV Midazolam (0.2 mg/kg bolus) IV Phenobarbitone (20mg/kg) Note Monitor BP, respiration Start inotropic support, especially if Midazolam/phenobarbitone is given Arrange for ICU Secure airway, prepare to use mechanical ventilation Titrate phenobarbitone to achieve burst suppression pattern on EEG If seizures persist despite 30mg/kg loading dose of phenobarbitone, contact higher up for discussion
  76. 76. FEBRILE CONVULSION By : Adam Safin bin Abdul Mutti
  77. 77. 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."
  78. 78. 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.
  79. 79. 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.
  80. 80. 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.
  81. 81. Type of febrile seizures
  82. 82. 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).
  83. 83. Continue… There are sign of increase intracranial pressure in meningitis, not in febrile seizure : Bulging fontanelle. Ptosis. Sixth nerve palsy.
  84. 84. Recurrent Febrile Seizures 30-40% 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.
  85. 85. 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.
  86. 86. 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.
  87. 87. Management and treatment of febrile convulsion
  88. 88. Call for help Evaluate and Resuscitate Glasgow coma scale Admit to ward Not all children are admitted to ward Investigation (lumbar puncture) Must be done if Sign of intracranial infection Prior antibiotic therapy Persistent lethargy and not fully interactive 6 hours after seizures Strongly recommended if Age < 12 months First complex febrile convulsion In district hospital without paediatrician Patient have a problem bringing the child in again if deterioration at home Febrile Convulsion
  89. 89. Control Fever Take of cloth and tepid sponging Antipyretic Monitor the patient condition Vital signs Counseled parents regarding the benign nature of the disease Advised parents on first aid measures during a convulsion Do not panic Loosen child cloth especially around neck Place child on left lateral position with head lower than body Wipe out any vomitus Don’t insert any object or drug Stay near the child
  90. 90. Rectal diazepam For parents whose children have high risk of recurrence febrile convulsion Convulsion last more than 5 minutes Prevention of recurrent febrile convulsions Anticonvulsants are not recommended for prevention of recurrent febrile convulsions