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Seizures in Childhood

Seizures in Childhood. Kitesh Moodley January 2009. Introduction. Convulsion associated with febrile disease 2-4% of all children before the age of 5 years Symptomatic seizures 0.5-1% Epilepsy: Recurrent unprovoked seizures First year of life: 1,2/1 000 Childhood and adolescents:

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Seizures in Childhood

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  1. Seizures in Childhood Kitesh Moodley January 2009

  2. Introduction • Convulsion associated with febrile disease • 2-4% of all children before the age of 5 years • Symptomatic seizures • 0.5-1% • Epilepsy: • Recurrent unprovoked seizures • First year of life: • 1,2/1 000 • Childhood and adolescents: • 0,5-1/10000

  3. Specific aetiology Identifiable in only 30% of cases Idiopathic 67.6% Congenital 20% Trauma HIE Congenital brain anomalies Trauma 4.7% Infection 4.0% Vascular 1.5% Neoplastic 1.5% Aetiology of Epilepsy

  4. Seizure type - Simple (Normal consciousness) - Complex (Impaired consciousness) Partial (Only a portion of the brain) Generalized (Both hemispheres are involved)

  5. Epilepsy classification • Clinical presentation is quite variable • age of onset • seizure type • interictal condition • EEG • Outcome • Evaluate the: • the epileptic syndrome • Possible aetiology • The seizure type and syndrome type determine the • Specific appropriate treatment • Further evaluation

  6. ILAE.org • Partial seizures • Simple • With motor symptoms • Autonomic symptoms • Psychic symptoms • Complex • Simple then altered LOC • Altered LOC from beginning • Simple or complex which become generalised

  7. Generalised Seizures • Absence • Myoclonic • Clonic • Tonic • Atonic • Tonic-clonic

  8. Epilepsy syndromes • Seizures may occur as partial or generalised • Further divided into • Idiopathic • Symptomatic • Cryptogenic • Special situations i.e febrile seizures

  9. Main Periods according to Age • Neonates • Subtle, erratic, non-febrile • Infancy and early childhood • 3 months to 3 years • Febrile seizures • Infantile spasms • Lennox Gastaut • Myoclonic seizures • Status epilepticus • Partial complex

  10. Main Periods according to Age • Childhood to early adolescence • Cryptogenic • Absences • Benign rolandic epilepsy • Nine years to adulthood • Primary generalized epilepsy • Focal epilepsy with brain injury

  11. Stats from ILAE • Primary tonic-clonic seizures 20% • Simple partial 20% • Absence seizures 10% (more in children) • Other 10% • 40% of Epilepsy in adults is Complex partial seizures

  12. Neonatal seizures • Subtle seizures • Deviation of the eyes • Eyelids are flickering • Swimming or pedaling movements • Apnoeic spells • Tonic • Clonic • Myoclonic • Seldom tonic clonic seizures

  13. Perinatal: HIE Metabolic Hypoglycemia, hypocalcemia hypomagnesemia Other Infections Structural abnormalities Aetiology of neonatal seizures

  14. Treatment of neonatal seizures • Optimize ventilation, cardiac output, BP, glucose, electrolytes and pH. • Treat the underlying disease • Intravenous line is essential • Treat the seizures promptly and vigorously • Phenobarbitone • Phenytoin

  15. Febrile seizures • Definition: • Seizure in children between the age of 6 months and 3-4(5) years in association with fever but without evidence of an intracranial infection • Majority occurs before the age of 3 years • Average age of onset: 18 months to 22 months • Boys more than girls

  16. Pathophysiology • Seizure threshold is low in children • Susceptible to infections i.e urti, LRTI • Possible role of endogenous pyrogens IL1 • May increase neuronal activity • Probable role of cytokines

  17. 2 Types • Simple febrile seizures • Generalise • <15min duration • Do not recur within 24hrs • Complex • Prolonged seizures • Usually more than one in a 24hr period • Or may be focal • Indicative of a more serious condition

  18. Febrile seizures • Recurrence • 1/3 may have at least one recurrence • The younger the age of onset the greater the risk of recurrence • Low fever at first seizure • Family hx • Risk of developing epilepsy • 2% (vs 1% in gen pop) • Risk increases with: • Complex • Abnormal neurological state

  19. Investigation of febrile seizures • Lab investigations, although routine, usually unhelpful, in the evaluation of first time seizure – possible just a Na and Glucose • CT is not warranted in the evaluation of simple febrile convulsions but considered for complex • Study of 71 patient with complex seizures • None had an intracranial condition requiring treatement • Routine EEG is seldom necessary • ??LP • Simple febrile seizure probable not indicated • Probable those with prolonged post-ictal phase • Current recommendation should be routine in the under 12 month group

  20. Treatment of febrile convulsion • Oxygen and supportive care • Benzodiazapines • Antipyretics • Do not appear to prvent recurrence • Councel parents

  21. Treatment of Epilepsy • Drug treatment should be regular • Simple as possible • Minimum of side effects • Monotherapy • Changes should be made gradually • High initial dosages increases side effects • Rapid withdrawal carries the risk of provoking status • Always calculate the dosage according to the weight

  22. Treatment of Epilepsy • Drugs commonly used • Carbamazepine • Sodium valproate • Clonazepam • Phenobarbitone • Phenytoin • Newer drugs • Clobazam • Oxcarbazepine • Gabapentin • Vigabatrin • Lamotrigine

  23. Treatment of Epilepsy • Antiepileptics can cause convulsions • Benzodiazepines can induce TC seizures in LGS • Carbamazepine may exacerbate absence seizures • What is used as first line treatment. • Absence: • Sodium valproate • Focal and Generalized TC: • Carbamazepine

  24. Status epilepticus (SE) presents in a multitude of forms, dependent on aetiology and patient age (myoclonic, tonic, subtle, tonic-clonic, absence, complex partial etc.) • Generalized, tonic-clonic SE (GCSE) is the most common form of SE

  25. Definition • Conventional “textbook” definition of status epilepticus: • Single seizure > 30 minutes • Series of seizures > 30 minutes without full recovery

  26. Why 30 minutes ? Animal experiments in the 1970s and 1980s had shown that ... … neuronal injury could be demonstrated after 30 min of seizure activity, even while maintaining respiration and circulation Nevander G. Ann Neurol 1985;18(3):281-90.

  27. More practical: Mechanistic definition • GCSE is a condition which most likely will not terminate rapidly and / or spontaneously • GCSE is a condition which requires prompt intervention Lowenstein DH. Epilepsia 1999

  28. The longer SE persists, • the lower is the likelihood of spontaneous cessation • the harder it is to control • the higher is the risk of morbidity and mortality Bleck TP. Epilepsia 1999;40(1):S64-6 The Status Epilepticus Working Party. Arch Dis Child 2000;83(5):415-9.

  29. Typical seizure duration • Children > 5 years: Typical, generalized tonic-clonic seizure lasts < 5 minutes • Young children and infants: little data. latsts < 10-15 minutes Reviewed in: Lowenstein DH. It's time to revise the definition of status epilepticus. Epilepsia 1999;40(1):120-2.

  30. Revised Definition • Generalized, convulsive status epilepticus in older children (> 5 years) refers to > 5 minutes of continuous seizure or >2 discrete seizures with incomplete recovery of consciousness

  31. Fever Medication change Unknown Metabolic Congenital Anoxic Other (trauma, vascular, infection, tumor, drugs) 36% 20% 9% 8% 7% 5% 15% Causes \

  32. 15 to 22% 3 to 15% Mortality • Adults • Children Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30

  33. Mortality • The primary determinant of mortality and morbidity of SE in children is its aetiology • With the highest mortality rates caused by an acute neurological condition (infection, trauma, stroke) Mitchell WG. J Child Neurol 2002;17 Suppl 1:S36-43.

  34. Prolonged seizures Life threatening systemic changes Temporary systemic changes Death Duration of seizure

  35. Respiratory • Hypoxia and hypercarbia • Ventilation • (chest rigidity from muscle spasm) • Hypermetabolism • ( O2 consumption, CO2 production) • Poor handling of secretions • Neurogenic pulmonary oedema

  36. Hypoxia • Hypoxia/anoxia markedly increase (triple?) the risk of mortality in SE • Seizures (without hypoxia) are much less dangerous than seizures and hypoxia Towne AR. Epilepsia 1994;35(1):27-34

  37. Acidosis • Respiratory • Lactic • Impaired tissue oxygenation • Increased energy expenditure

  38. Haemodynamics • Sympathetic overdrive • Massive catecholamine / autonomic discharge • Hypertension • Tachycardia • Exhaustion • Hypotension • Hypoperfusion 0 min 60 min

  39. Cerebral blood flow - Cerebral O2 requirement • Hyperdynamicphase • CBF meets CMRO2 • Exhaustion phase • CBF drops as hypotension sets in • Autoregulation exhausted • Neuronal damage ensues O2 requirement Blood flow Blood pressure Hyperdynamic Exhaustion Seizure duration Lothman E. Neurology 1990;40(5 Suppl 2):13-23.

  40. Glucose SE 30 min SE + hypoxia Seizure duration Glucose • Hyperdynamicphase • Hyperglycemia • Exhaustion phase • Hypoglycemia develops • Hypoglycemia appears earlier in presence of hypoxia • Neuronal damage ensues Lothman E. Neurology 1990;40(5 Suppl 2):13-23.

  41. Hyperpyrexia • Hyperpyrexia may develop during protracted SE which impairs substrate delivery while increasing metabolic demand • Treat hyperpyrexia aggressively • Antipyretics, external cooling • Ensure normal temperatures

  42. Other alterations • Increase WCC (50% of children) • Spinal fluid leukocytosis (15% of children) • K+ • creatine kinase • Myoglobinuria

  43. A Oxygen, oral airway. Suction. Avoid hypoxia! Consider bag-valve mask ventilation. Consider intubation IV/IO access. Treat hypotension, but NOT hypertension B C

  44. Treatment Intubate? • It may be difficult to intubate a child with active seizures • Stop or slow seizures first, give O2, consider BVM ventilation • If using paralytic agent to intubate, assume that SE continues

  45. Initial investigations • Labs • Na, Ca, Mg, PO4 , glucose • WCC • Liver function tests, ammonia • Anticonvulsant drug level • Toxicology

  46. Initial investigations • Lumbar puncture • Always defer LP in unstable patients, but never delay antibiotic/antiviral treatment if indicated • CT scan • Indicated for focal seizures or focal deficit or focal EEG, history of trauma or bleeding disorder Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA 1993;270(7):854-9.

  47. Treatment • Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%), unless normo- or hyperglycemic • Hyperglycemia has no negative effect in SE

  48. Treatment • The longer you wait to administer anticonvulsants, the more anticonvulsants you will need to stop SE • Most common mistake is ineffective dose

  49. Anticonvulsants • Rapid acting plus • Long acting

  50. Anticonvulsants - Rapid acting • Benzodiazepines • Lorazepam 0.1 mg/kg i.v. over 1-2 minutes • Diazepam 0.2 mg/kg i.v. over 1-2 minutes • If SE persists, repeat every 5-10 minutes

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