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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

Seizures in Childhood

Kitesh Moodley

January 2009

introduction
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
aetiology of epilepsy
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
seizure type
Seizure type

- Simple

(Normal consciousness)

- Complex

(Impaired consciousness)

Partial

(Only a portion

of the brain)

Generalized

(Both hemispheres are

involved)

epilepsy classification
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
ilae org
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
slide7
Generalised Seizures
    • Absence
    • Myoclonic
    • Clonic
    • Tonic
    • Atonic
    • Tonic-clonic
epilepsy syndromes
Epilepsy syndromes
  • Seizures may occur as partial or generalised
  • Further divided into
    • Idiopathic
    • Symptomatic
    • Cryptogenic
  • Special situations i.e febrile seizures
main periods according to age
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
main periods according to age10
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
stats from ilae
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
neonatal seizures
Neonatal seizures
  • Subtle seizures
    • Deviation of the eyes
    • Eyelids are flickering
    • Swimming or pedaling movements
    • Apnoeic spells
  • Tonic
  • Clonic
  • Myoclonic
  • Seldom tonic clonic seizures
aetiology of neonatal seizures
Perinatal:

HIE

Metabolic

Hypoglycemia, hypocalcemia

hypomagnesemia

Other

Infections

Structural abnormalities

Aetiology of neonatal seizures
treatment of neonatal seizures
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
febrile seizures
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
pathophysiology
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
2 types
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
febrile seizures18
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
investigation of febrile seizures
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
treatment of febrile convulsion
Treatment of febrile convulsion
  • Oxygen and supportive care
  • Benzodiazapines
  • Antipyretics
    • Do not appear to prvent recurrence
  • Councel parents
treatment of epilepsy
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
treatment of epilepsy22
Treatment of Epilepsy
  • Drugs commonly used
    • Carbamazepine
    • Sodium valproate
    • Clonazepam
    • Phenobarbitone
    • Phenytoin
  • Newer drugs
    • Clobazam
    • Oxcarbazepine
    • Gabapentin
    • Vigabatrin
    • Lamotrigine
treatment of epilepsy23
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
slide24
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
definition
Definition
  • Conventional “textbook” definition of status epilepticus:
    • Single seizure > 30 minutes
    • Series of seizures > 30 minutes without full recovery
why 30 minutes
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.

more practical mechanistic definition
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

slide28
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.

typical seizure duration
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.

revised definition
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
causes
Fever

Medication change

Unknown

Metabolic

Congenital

Anoxic

Other (trauma, vascular, infection, tumor, drugs)

36%

20%

9%

8%

7%

5%

15%

Causes

\

mortality
15 to 22%

3 to 15%

Mortality
  • Adults
  • Children

Reviewed in: Fountain NB. Epilepsia 2000;41 Suppl 2:S23-30

mortality33
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.

prolonged seizures
Prolonged seizures

Life

threatening

systemic

changes

Temporary

systemic

changes

Death

Duration of seizure

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

acidosis
Acidosis
  • Respiratory
  • Lactic
    • Impaired tissue oxygenation
    • Increased energy expenditure
haemodynamics
Haemodynamics
  • Sympathetic overdrive
    • Massive catecholamine / autonomic discharge
    • Hypertension
    • Tachycardia
  • Exhaustion
    • Hypotension
    • Hypoperfusion

0 min

60 min

cerebral blood flow cerebral o 2 requirement
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.

glucose

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.

hyperpyrexia
Hyperpyrexia
  • Hyperpyrexia may develop during protracted SE which impairs substrate delivery while increasing metabolic demand
  • Treat hyperpyrexia aggressively
    • Antipyretics, external cooling
    • Ensure normal temperatures
other alterations
Other alterations
  • Increase WCC (50% of children)
  • Spinal fluid leukocytosis (15% of children)
  • K+
  • creatine kinase
  • Myoglobinuria
slide43

A

Oxygen, oral airway. Suction. Avoid hypoxia!

Consider bag-valve mask ventilation. Consider intubation

IV/IO access. Treat hypotension, but NOT hypertension

B

C

treatment
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
initial investigations
Initial investigations
  • Labs
    • Na, Ca, Mg, PO4 , glucose
    • WCC
    • Liver function tests, ammonia
    • Anticonvulsant drug level
    • Toxicology
initial investigations46
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.

treatment47
Treatment
  • Give glucose (2-4 ml/kg D25%, infants 5 ml/kg D10%), unless normo- or hyperglycemic
  • Hyperglycemia has no negative effect in SE
treatment48
Treatment
  • The longer you wait to administer anticonvulsants, the more anticonvulsants you will need to stop SE
  • Most common mistake is ineffective dose
anticonvulsants
Anticonvulsants
  • Rapid acting

plus

  • Long acting
anticonvulsants rapid acting
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
benzodiazepines
Diazepam

High lipid solubility

Thus very rapid onset

Redistributes rapidly

Thus rapid loss of anticonvulsant effect

Adverse effects are persistent:

Hypotension

Respiratory depression

Lorazepam

Low lipid solubility

Action delayed 2 minutes

Anticonvulsant effect 6-12 hrs

Less respiratory depression than diazepam

Midazolam

May be given i.m.

Benzodiazepines
benzodiazepine intramuscular
Benzodiazepine - Intramuscular
  • Intramuscular midazolam
    • 0.2 mg/kg i.m.
    • Aqueous solution is rapidly absorbed, anticonvulsant effect begins after 2 minutes
  • Intramuscular lorazepam
    • Can be given, but lacks water solubility, thus later onset than midazolam

Chamberlain JM. Pediatr Emerg Care 1997;13(2):92-4.

Towne AR. J Emerg Med 1999;17(2):323-8.

anticonvulsants long acting
Phenytoin

20 mg/kg i.v. over 20 min

pH 12

Extravasation causes severe tissue injury

Onset 10-30 min

May cause hypotension, dysrhythmia

Anticonvulsants - Long acting
anticonvulsants long acting54
Anticonvulsants - Long acting
  • Phenobarbital
    • 20 mg/kg i.v. over 10 - 15 min
    • Onset 15-30 min
    • May cause hypotension, respiratory depression
    • Neurology RXH : no upper limit to phenobarb
      • High dose phenobarb for SE will prob need icu admission
if se persists
If SE persists
  • Propofol infusion 5-10 mg/kg/hr after bolus 2 mg/kg
  • Midazolam infusion 1 - 10 mcg/kg/min after bolus 0.15 mg/kg
  • Isoflurane
non convulsive status epilepticus
Non - convulsive status epilepticus
  • How do you tell that patient’s seizures have stopped?
non convulsive se
Non - convulsive SE ?
  • Neurologic signs after termination of SE are common:
    • Pupillary changes
    • Abnormal tone
    • Abnormal Babinski reflex
    • Posturing
    • Clonus
    • May be asymmetrical
non convulsive se58
Non - convulsive SE ?
  • Up to 20% of children with SE have non - convulsive SE after tonic - clonic SE
  • Particularly common in infants < 2 months

Mitchell WG. J Child Neurol 2002;17 Suppl 1:S36-43.

non convulsive se59
Non - convulsive SE ?
  • If child does not begin to respond to painful stimuli within 20 - 30 minutes after tonic - clonic SE stops, suspect non - convulsive SE
    • Urgent EEG
and remember
And Remember
  • Airway
  • Breathing
  • Circulation
  • Don’t
  • Ever
  • Forget
  • Glucose