Pediatric Seizures

Muhammad Waseem, MD Emergency Medicine Lincoln Hospital

Few things are more frightening to parents than to witness their child having a seizure

Objectives
    

Wide spectrum of Pediatric seizure Etiologies specific to children Treatment modalities in children Quality of life issues Legal implications

Seizure
   

Common neurologic disorder 3 - 5% of children 1/2 classified as febrile seizures Epilepsy (0.5 - 1%)

Seizure
  

10% ambulance calls for children 1.5% of total ED visit Most resolve in the pre-hospital setting

Seizure - ED visits
   

Febrile seizure Established epilepsy New-onset seizure Status epilepticus

53% 31% 10% 5%

Causes
    

Idiopathic Developmental Infection Head trauma Other

76% 13% 5% 3% 2%

Seizure
   

Fit Spell Attack Convulsion

What is Seizure?

Seizure


Paroxysmal, time-limited event that results from abnormal neuronal activity in the brain Paroxysmal alteration in neurologic function (i.e, behavioral, motor, or autonomic function, or all three - volpe 1989.

Convulsion


A seizure with prominent motor manifestation

Epilepsy


 

Disorder of CNS whose symptoms are seizures Recurrent seizures Unprovoked

Seizure
 

Most seizures are not epileptic Non-epileptic seizures are physiologic

  

Hypoxia Fever Toxins

Seizure


 

Seizure is a symptom of a disorder that need further investigations Does not constitute a diagnosis May occur in both normal & abnormal tissue

Non-epileptic Events

Mimic Seizures
     

Breath-holding spells Syncope Migraine Tics Night terror Pseudo-seizures

Non-epileptic Events
 

Inaccurate diagnoses Inappropriate use of AED

Non-epileptic Events
Careful history

Breath-holding spells
  

Frightening 6 months - 4 years Inciting event-Shrill cry-Breath holdingCyanosis Disappear spontaneously before school age

Night Terrors
      

5 - 7 years Between midnight and 2 AM Slow wave sleep stage 3 or 4 Frightened and screaming Increased autonomic activity Sleep follows in few minutes No recall

Pseudo-seizure
     

Diagnosis of exclusion 10 - 18 years Bizarre, unusual postures Verbalization Uncharacteristic movements Can be persuaded to have an attack on request

Pseudo-seizure
      

Lack of cyanosis Talking during seizure Normal reaction to pupil No loss of sphincter control Normal plantar responses Lack of post-ictal drowsiness Poor response to AED

Seizure


First step in identifying the epileptic syndrome is correctly identifying the type of seizure

Why Should I know type of Seizure?

Seizure
  

Clue to cause Appropriate treatment Prognosis

Epileptic Seizures
  

Partial (40%) Generalized Unclassified

Partial Seizure
  

Simple Partial Complex Partial Partial with secondary generalization

Generalized
 

Convulsive Non convulsive



Absence Seizure

Generalized- Convulsive
    

Myoclonic Clonic Tonic Tonic-clonic Atonic

Simple Partial Seizures (SPS)

   

Consciousness not altered Aura Motor activity (face, neck or extremity) Feeling funny or something crawling inside me No post-ictal phenomenon

Complex Partial Seizures (CPS)

  

Impairment of consciousness Aura Brief blank stare or sudden cessation or pause in activity Automatism (lip smacking, chewing, swallowing and excessive salivation)

Complex Partial Seizures (CPS)



  

Dystonic posturing, tonic or clonic movement Postictal phase Duration 1 - 2 minutes Usually during waking hours

Absence Seizure


 

Sudden cessation of motor activity or speech Blank facial expression Flickering of eye lids

Absence Seizure
    

Uncommon before age 5 year Girls No Aura No postictal state Rarely persist longer than 30 sec

Absence Seizure


Hyperventilation induces an absence seizure 3/sec spike on EEG

Myoclonic
   

Quick muscle jerks Loss of body tone Consciousness usually unimpaired Specific epilepsy syndromes

Tonic


 

Tonic spasms of truncal & facial muscles Flexion of upper extremities Extension of lower extremities

Clonic
  

Resembles myoclonus Loss of consciousness Slower

Tonic-clonic
   

 

Extremely common Begins suddenly without warning Tonic contraction of the trunk Rhythmic clonic contraction alternating with relaxation of all muscle groups Marked increase in HR and BP incontinence

Tonic-clonic
 

Seizure last 1 to 2 minutes Post-ictal 30 minutes to 2 hours

Atonic Seizures
  

Suddenly dropping to the floor Lanox-Gastaut syndrome Can occur without LOC

Case 1

Case 1
 

9-year-old boy Parents were aroused one night by noise from his bed room Noted bed sheets awry & breathing deeply bitten his tongue

Case 1
 

Confused Afebrile

First Non-Febrile Seizure

History


Was this a true seizure or a nonepileptic event?

History


Circumstances
 

Normal activity vs. provoked Upon awakening

   

Duration Aura Abnormal motor movements Abnormal eye movements/automatism

History
     

Post-ictal period Urinary or fecal incontinence Fever, trauma or drug Birth history Delayed milestones Family history of seizures

Physical Examination
  

Vital signs Level of consciousness Head circumference (percentile)

Always undress and examine the child

Caf-au-lait spot
    

Uniformly hyper-pigmented sharply demarcated macules Normal children (1-3 spots) 10% of normal children May be present at birth or develop later

Neurofibromatosis (NF-1)
  

Six or more, >5 mm in prepubertal Six or more, >15 mm in postpubertal Crowe sign


freckled appearnace in axilla

Neurofibromatosis (NF-1)
  

 

Present in 100% of patients present at birth Increase in size, number & pigmentation Predilection for trunk & extremities Spare face

Lisch nodules
  

Pigmented hamartomas of the iris NF-1 Prevalence increases with age

  

5% 42% 100%

(<3 years) (3-4 years) (21 years)

Lisch nodules
 

 

Asymptomatic Do not correlate with the extent & severity Do not occur in normal individuals Best identified with slit lamp

Adenoma Sebaceum


  

Erythematous papules over nose & malar areas Develop between 4 and 6 years of age coalesce & assume fleshy appearance Tuberous sclerosis

Ash-leaf spots
    

Hypo-pigmented Irregular borders May be present at birth Detectable by 2 years in 50% Wood s ultraviolet lamp

Shagreen patch
  

Roughened raised lesion Orange-peel consistency Primarily lumbo-sacral area

Tuberous Sclerosis
 

Infantile spasm Hypsarrhythmic EEG pattern

CT Scan


Periventricular calcifications

MRI


Multiple cortical tubers

Port-wine stain
    

Macular cutaneous nevus Present at birth Always involves upper face & eye lids unilateral Sturge-Weber Disease

Port-wine stain


 

Tonic clonic seizure contralateral to the side of facial nevus Refractory to anticonvulsant hemiparesis

CT Scan
   

Normal at birth Gyriform contrast enhancement Hemispheric atrophy Parenchymal calcification



Railroad track

Physical Examination
   

Caf-au-lait spots (NF) Adenoma sebaceum (TS) Facial hemangioma (Sturge-Weber) Petechiae (meningitis)

Physical Examination
   

Hematoma or skull fractures Signs of raised ICP Retinal hemorrhages (Child abuse) Signs of meningeal irritation

Diagnostic Evaluation
    

Bedside glucose Serum Ca & Mg (< 3 months old) Urine drug screen CT head Outpatient EEG

Rolandic Epilepsy
Benign Partial Epilepsy with Centrotemporal Spikes (BPEC)

Rolandic Epilepsy
     

Common in childhood 2 - 14 years Peak age 9 -10 years Normal children Unremarkable past history Normal neurologic examination

Rolandic Epilepsy
      

Simple partial seizure 3-13 years (peak 9-10 years) Almost always at night (75% sleep) EEG (centrotemporal spike) Carbamazepine Excellent prognosis Spontaneous remission by age 15 year

Infantile Spasm (West s synd)

    

Sudden jerks of group of muscles 4-12 months Characteristic EEG (hypsarrhythmia) Poor prognosis ACTH/Steroid

Case 2

Case 2


7-month-old boy with runny nose and fever. His pediatrician saw him & diagnosed URI. He received tylenol. On the same afternoon while sitting on his mother s lap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted approx 5 minutes

Case 2
      

He fell asleep after the seizure. Normal development T 102 F, HR 124, R 30 BP 90/50 Wt 7.9 Kg (50%) Ht 66.5 cm (50%) HC 44 cm (50%) No NC lesions

Febrile Seizures

Febrile seizures


Most common type of seizures in the pediatric age usually benign Can cause considerable parental anxiety

 

Febrile seizures


Seizures that occur in infancy or childhood usually occurring between 3 months and five years, associated with fever, but without evidence of intracranial infection or defined cause

Febrile Seizures
     

Age dependent Rare before 9 months & after 5 years Peak age 9-20 months Incidence 3 - 4% Family history Diagnosis of exclusion

Febrile Seizures


Risk factors
  

Height of temperature Male sex Family history of febrile seizure

Febrile Seizures


A family history of epilepsy has not been shown to be a risk factor for first febrile seizures

Febrile Seizures


Risk factors for recurrence

  

Young age at onset Febrile seizures in first degree relative Lower degree of fever

Febrile Seizures
   

Generalized tonic-clonic Duration few seconds to 10 minutes Excellent prognosis 20% are complex

Febrile Seizures


Complex febrile seizure

  

> 15 minutes More than once in 24 hours Focal neurologic features

Febrile Seizures
 

Risk of recurrence 34% Most recurrences within 6-12 months

Lumbar Puncture


The decision to perform LP should be based on the age of the child at presentation (AAP)

Lumbar Puncture


< 12 months


Strongly recommend Should consider If history & physical examination suggest intracranial infection

12 - 18 months


> 18 months


Febrile Seizures


Signs of meningeal irritation



Unreliable under 18 months

Red flags
 

Focal seizure Suspicious physical examination findings (eg, rash, petechiae) cyanosis, hypotension, or grunting Abnormal neurologic examination

Febrile Seizures


Meningitis must be ruled out



Difficult if the patient is on antibiotics

Febrile Seizures
   

Determine and treat the cause of fever IV benzodiazepine Rectal diazepam No routine AED prophylaxis

Febrile Seizures


Incidence of epilepsy
 

1% (No other risk factor) 9% (Other risk factors)

Epilepsy
  

Family history of later epilepsy Preexisting neurologic abnormality Complex febrile seizure
 

> 15 minutes duration > 1 febrile seizure per 24 hour

Focal febrile seizure

Neonatal Seizures

Neonatal Seizures
  

Seizures during first 28 days 0.5% of all live births Do not indicate epilepsy

Jitteriness Vs Seizure
    

Movements are stimulus sensitive Appear during active state (crying) Disappear on passive flexion Not jerky No abnormal eye movements

Neonatal Seizures


Neonates are at particular risk

   

Metabolic Toxic Structural Infectious

Neonatal Seizures


Not generalized tonic-clonic



incomplete myelination

 

Can be very subtle Minimal physical findings

Neonatal Seizures
   

Subtle Tonic Clonic Myoclonic

Subtle Seizure
     

More common in premature infants Eye deviation + jerking eyelid blinking fluttering smacking or drooling Apneic spells

Causes
    

Perinatal asphyxia Intracranial hemorrhage Metabolic - hypoglycemia, hypocalcemia Infections Drug withdrawl

History


Family history


metabolic

 

Maternal drug history Delivery

  

Mode & nature of delivery Fetal intrapartum status Resuscitative measures

Physical Examination
    

Gestational age Blood pressure Presence of skin lesions Presence of hepatosplenomegaly Neurologic evaluation

Lab
  

Serum chemistry Spinal fluid Metabolic work-up

 

serum ammonia amino-acids

Lab


Head sonogram


IVH/periventricular Hemorrhage Calcifications Malformations

CT head
  

EEG

Management


The method of treatment depends on the cause Anticonvulsant



Phenobarbital

Status Epilepticus

Status Epilepticus
 

Seizure >30 minutes Intermittent seizures longer than 30 minutes from which the patient does not regain consciousness

Status Epilepticus (SE)



 

Highest incidence in very young children 5% of ED visit of seizing children 70% of children with epilepsy experience at least one episode of SE Mortality rate 8 to 32%

Status Epilepticus (SE)

   

Any type of seizure Generalized (most common) Absence or partial (10%) Febrile SE (25%)

Life-threatening causes
    

Bacterial meningitis Hypoglycemia Increased intra-cranial pressure Hypoxemia Toxins



TCA, Cocaine, Theophylline, insulin

Management


Rapid stabilization of cardio-respiratory functions Termination of both clinical & electrical seizures Diagnosis & treatment of life threatening precipitant

Status Epilepticus


The child is often given too much IV benzodiazepine .Blood gases are measured and perhaps the values are found to be slightly decreased. The child is then paralyzed, intubated, and sent to the intensive care unit to recover from the iatrogenic morbidity.

Status Epilepticus


Freeman JM: Status epilepticus: It s not what we ve thought or taught. Pediatrics 1989;83:444-445

Status Epilepticus
  

Primary goal is to stop the seizure First line (benzodiazepine) Second line (phenytoin or fosphenytoin)

Diazepam
   

Rapid onset (3 - 5 minutes) Orally, IV, IM, IO or Rectal Duration of action 20 - 30 minutes Respiratory depression, sedation, hypotension Diastat (rectal gel)

Diazepam
 

IV 0.1 - 0.5 mg/kg Rectal 0.2 - 2 mg/kg (maximum 10 mg)

Lorazepam
      

Slower onset Longer duration (12 - 24 hours) Orally & IV Inappropriate for rectal administration 0.05 - 0.2 mg/kg Must be refrigerated Tachyphylaxis

Phenobarbital
 

 

Long duration (24 hours) IV 10-20 mg/kg bolus rate 1-2 mg/kg/min Intubation (>30-40 mg/kg) Respiratory depression, hypotension & bradycardia

Phenytoin


  

1950 - Massachusetts General Hospital pH 12, limited solubility in water Propylene glycol & ethanol 1956 - Parenteral formulation approved 1962 - pediatric dose recommendation 1986 - Revised Pediatric dose (15-20 mg/kg, 1-3 mg/kg/min)

Phenytoin


High pH
 

Burning & cutaneous reactions Purple glove syndrome

Phenytoin


Propylene glycol
      

Seizures Arrhythmia Asystole Hepatic & renal damage Hemolysis Hyperosmolality Lactic acidosis

Phenytoin


The amount of propylene glycol in a typical loading dose of phenytoin administered to a 1 kg premature neonate is about seven times greater than WHO standard

Fosphenytoin 1996
     

Pro-drug of phenytoin pH 8 Far more soluble in water No organic solvent Both IV & IM Rapid & complete conversion to phenytoin

Sports Participation

Sports Participation
 

Unnecessary restrictions Successful athelete with epilepsy



Gary Howatt (hockey player)

Sports Participation
  

Which sport Common sense Significant metabolic imbalance



Scuba diving

Potential for serious injury

AMA Committee for Sports



Patients with epilepsy will not be affected by indulging in any sport, including football, provided the normal safegaurds for sports participation are followed, including adequate head protection

Permitted Sports
      

Baseball basketball broad jumping hockey gymnastic Soccer wrestling

Reasonable precautions
    

Bicycling Diving Football Skating Swimming

Prohibited Sports
     

Boxing Bungee jumping Polo Scuba diving Skydiving Waterskiing

Driving & Regulatory Issues

Driver Licensing
 

Each state has its own regulations Seizure free period



1 Year (NY)

Reporting responsibility
 

Patient responsibility Physician responsibility



(most states) (Six states)

CA, DE, NE NJ, OR, PA

Employment

Employment
  

Average intelligence Good health Unpredictable loss of consciousness

Employment
 

No hard-and-fast rules Should avoid workplaces in which a sudden loss of consciousness may expose them or their coworkers to risk or injury

Employment
  

Interstate truck Forklift Working in heights

Pregnancy & Epilepsy

Pregnancy & Epilepsy

 

20,000 births women with epilepsy Lower seizure threshold

Offspring & AED

Offspring & AED



Pheytoin


fetal hydantoin syndrome neural tube defect spina bifida

Valproate


Carbamazepine


Labor & Delivery

Labor & Delivery



Bleeding tendency in neonate

 

induction of hepatic enzymes overcome by Vitamin K

Breast feeding & AED

Breast feeding & AED



    

Nearly all epileptic drugs are transferred in breast milk Phenytoin 18% Phenobarbital 36% Carbamazepine 41% Valproate 5% Breast feeding is not contraindicated

Oral contraceptives & AED

Oral contraceptives & AED



Increase the dose of Oral contraceptives (AED induces hepatic metabolism of hormones)

Don t forget child abuse

Discrepancy between history & injury

You are mandated by law to protect these children

It s not optional


New York State Law (Social Services Law Section 413) requires that any health professional who suspects that a child is being endangered or maltreated must report his/her suspicion to NY City, to the local child protection services

New AED s

New AED s
   

Gabapentin (Neurontin) Lamotrigine (Lamictal) Vigabatrin (Sabril) Felbamate (Felbatol)

Take home message

    

Wide range of presentation Efficiently obtain information Always undress & examine Establish underlying etiology Suspect abuse with inconsistent history