Transcript Pediatric Seizures

Pediatric Seizures
Jeffrey Frank
Child Neurology
Oregon Neurology Associates
Disclosure
• I do not have a financial interest, arrangement
or affiliation with any organizations that could
be perceived as a real or apparent conflict of
interest in the context of the subject of this
presentation.
Seizures Historically
• Ancient Babylonia
– Miqtu – “the falling disease”
– If a person loses consciousness and foams at the
mouth, it is Miqtu
– Miqtu – ‘to possess’
• Ghosts and demons
Seizures Historically
• Hippocrates
– Not a sacred disease
– First to describe epilepsy as a brain disorder
• The Falling Sickness
• Shakespeare – Epilepsy
– Othello 1603
– Epilepsia
• to seize
• to be taken hold of
Seizure
• Old French ‘seisir’ – to take possession by
force
• Popular – sudden and severe event
• Medically – transient occurrence of signs
and/or symptoms due to abnormal, excessive
or synchronous neuronal activity in the brain
– Epileptic Seizure
Epilepsy
• Historical - Two or more unprovoked seizures
• ILAE 2005 - disorder of the brain characterized
by an enduring predisposition to generate
epileptic seizures and by the neurobiologic,
cognitive, psychological, and social
consequences of this condition. The definition
of epilepsy requires the occurrence of at least
one epileptic seizure
Epilepsy
• At least two unprovoked (or reflex) seizures occurring
greater than 24 hours apart.
• One unprovoked (or reflex) seizure and a probability of
further seizures similar to the general recurrence risk
(at least 60%) after two unprovoked seizures, occurring
over the next 10 years.
• Diagnosis of an epilepsy syndrome
– Epilepsy is considered to be resolved for individuals who
had an age-dependent epilepsy syndrome but are now
past the applicable age or those who have remained
seizure-free for the last 10 years, with no seizure
medicines for the last 5 years.
Seizure?
• Popular – sudden and severe event
• Medical
– Epileptic seizure
• Synchronous neuronal activity
– Nonepileptic seizure
Nonepileptic Seizures
• Psychogenic
– Psychologically induced
– Behavioral episode
• Nonpsychogenic
– “Organic” but not of epileptic origin
Nonpsychogenic
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“Organic”
Typically not responsive to anticonvulsants
May still be stereotyped
Any age
Nonepileptic Childhood Events
Breath Holding Spells
• Typically 6mos to 2yrs
– Can extend to 5-6 years
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Provoked
Gasp  Apnea  Pallor/cyanosis
Altered sensorium, stupor or syncope
Twitches or jerking movements
Breathing returns after syncope
Child typically recovers quickly
Benign Sleep Myoclonus
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Sudden, quick, jerk-like movement
In sleep
Not rhythmical
Patient can be woken
Stereotypies
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Rigidly, repetitive and invariable
Inappropriate in nature
Head Banging
Hand Flapping
Body Rocking
Toe Walking
Echolalia
Benign Paroxysmal Vertigo
• Sudden onset dizziness or ataxia
– Can be provoked by vestibular stimulation
• Typically lasts minutes
– Can last up to 2 days
• May act very scared
• Often hold on to people/objects
• May be accompanied by headache
Non Epileptic All Ages
Migraine Variants
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Hemiplegia
Loss of vision
Aphasia / slurred speech
Confusion
Fluctuating consciousness
Visual auras
Vertigo
Syncope
• Often preceded by symptoms
– Dizziness, darkening vision, weakness
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Loss of tone / Limp
Pallor / Cyanosis
Eyes closed
May have convulsive mvmts
Lucid on wakening
Tics
• Stereotyped
• Multiple versions
– Motor or Vocal
• Suppressible
• Can be complex
“Normal” Behavior
• Daydreaming
• Sleep
• Confusional Arousal
Epileptic Seizures
• Stereotyped complex movements
– May be focal or generalized
– Though student may have multiple types
– Evolution
• Paroxysmal
– Clear beginning and end
• Involuntary / Uncontrollable
• Not distractible / interruptible
• Post-ictal phase
Generalized Seizure Types
• Generalized Tonic Clonic
– ‘Grand Mal’
• Tonic Seizure
– Stiffening
• Myoclonic Seizure
– Jerk-like movements
• Atonic
– Sudden loss of postural tone
• Absence
– ‘Petit mal’
Focal Seizure Types
• Focal Motor seizure
– Sustained, rhythmical movements
– May progress, migrate or generalize
• Clonic
– Jerking movements
• Complex Partial
– Alteration of awareness
– Staring
• Autonomic
Psychogenic Nonepileptic
• “Pseudoseizure”
• Psychological / Psychiatric / Behavioral
– Subconscious/unconscious symptoms
• Somatization Disorder
• Conversion
– Conscious
• Factitious
• Malingering
– Anxiety
Epileptic vs Psychogenic
Epileptic
Psychogenic
Eyes open
Eyes closed
Continuous w/evolution
Stop and go
Rhythmical movements
Erratic / ‘thrashing’
Guttural sounds, aphasia
Stuttering
Fetal position, flexion
Opisthotonic, arching
Emesis
Crying
Tonic stiffening
Thrusting
Unresponsive*
Responsive / aware*
Amnesia*
Recollection of event*
*Patient may retain partial awareness/memory w/focal seizure
Acute Intervention
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Remain calm
Check the time
Thoughtfully observe while acting
Check for medical ID / Seizure plan
Place/roll patient to side
– Prevent fall / gently help from chair/standing
• Do not restrict movements
– Cushion if possible
• Do not put anything into mouth
– Including medications
When to call EMS
• Any signs of cardiorespiratory compromise
• No known seizure disorder
– No seizure action plan or
– If seizure action plan indicates
• Seizure does not show signs of stopping after 5
minutes
• Second seizure begins before patient returns to
neurological baseline
• Any signs of physical injury
• Unexpected focal neurological findings
After the Seizure
• Document details of seizure
– Time of onset
– Length
– Description of movements, evolution
– Triggers?
– Post-ictal phase?
– Awareness/responsiveness?
Medication Intervention
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Diastat – prepackaged rectal diazepam
Dosing should be pre-dialed
Rectal administration
Typically administered if seizure > 5 min
May cause side effects
– Drowsiness
– Confusion
• Minutes
Intranasal Midazolam
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May need to be drawn up
½ total dose in each nostril
Typically for seizure > 5min
May cause side effects
– Drowsiness
– Confusion
• Minutes
Oral Medications
• Rarely used
• Not to be given during seizure effective
consciousness / swallowing ability
• May have role for cluster of events
Home?
• No EMS criteria
• Rapidly / progressively recovering
• No known triggers
– Missed doses
– Intercurrent illness / fever
– Sleep deprived
• No history of clusters