Transcript Febrile Seizures

Seizures in Childhood
CME November 2-4, 2013
Dr. Lumphoon
Pre-Test
1) What is the most common cause of
childhood seizures?
a) poisoning
b) birth trauma
c) fever
d) head trauma
Pre-test
2) What drug should you use to stop a seizure
that has lasted 4 minutes?
a) phenobarbital
b) diazepam
c) phenytoin
d) don’t treat unless seizure has lasted at
least five minutes
Pre-test
3) When a child has a seizure, when is a lumbar
puncture indicated?
a) In every case
b) Only if there are signs of increase intracranial
pressure
c) If there is fever and neck stiffness, and
meningitis is being considered
d) If the child has a red throat
Pre-test
4) What is the first thing you do when
confronted by a seizing patient?
a) ABC’s , recovery position, glucose
b) Draw blood for electrolytes and glucose
c) Administer bicarbonate to counteract
metabolic acidosis
d) Observe to see how long the seizure is
going to last
Pre-test
5) What is the most important part of chronic
seizure management in children?
a) Use of two medications for seizure control
b) Discovering the family’s knowledge level and
educating them as much as possible about
the seizures and what to do.
c) CT scan of the brain
d) Educate the community about the seizures
e) b and d
Seizure Definition
• Transient, paroxysmal, involuntary events
characterized by alterations of consciousness,
behavior, motor skills, autonomic activity, or
sensation.
• Results from abnormal, involuntary rhythmic
discharges from a group of neurons in the
brain.
• A seizure is a sign of underlying disease, not a
disease itself.
Status Epilepticus
• Status epilepticus involves continuous seizure
activity or intermittent seizure activity without
full recovery for a period of 30 minutes or
longer.
• Status epilepticus is an emergency.
• These seizures need to be stopped, and the
etiology needs to be addressed to avoid
neurological damage.
Epilepsy
• The term ”epilepsy” refers to that state of
susceptibility of a child or adult to recurrent
seizures.
Case 1
• Noy is a 3- year old girl who presents to your
clinic with a history of fever for two days. She
now has had a seizure which first occurred
this morning.
• Noy is accompanied by her grandfather.
Case 1
• Noy is sleeping comfortably in grandfather’s
lap and appears stable.
• What questions do you need to ask her
grandfather about the seizures?
Case 1
• WWQQAAAB
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Where
When
Quantity
Quality
Aggravating factors
Alleviating factors
Associated factors
Belief about symptoms
Short differential
• What is your short differential diagnosis?
Case 1
• What other relevant history do you request?
Case 1
• Past Medical History: Previous seizures, prematurity,
prenatal, intrapartum or neonatal problems
• Development: Past development, any regression.
• Family History of seizures, epilepsy (higher occurrence
of both with positive family Hx)
• Social History: Why has her grandfather brought her?
• Immunization status
• Medication
• Allergies
• Pets, Travel
• Review of Systems
Case 1
• Noy has been previously healthy. Normal
development so far. Her grandfather doesn’t
think she has had any immunizations yet.
• One of Noy’s teenage sisters has had seizures
intermittently since she was a 2 year old.
• Noy lives with her grandfather because both
her parents died “in an accident”.
Case 1
• What is your problem list?
• Is there any change to your differential
diagnosis ?
• May use VITAMIN CDP to generate a larger
Differential Diagnosis.
Case 1
• Just as you prepare to do a physical exam,
Noy stiffens in all limbs, her eyes roll back
and she begins shaking rhythmically.
Case 1
• What do you think is happening?
• What do you do?
Case 1
• It seems like Noy is having a seizure but you
need to distinguish seizure from jitteriness or
rigors/chills
• You cannot stop a limb which is seizing by
holding it (this trick is especially useful in
neonates)
• Level of consciousness will be impaired if this
is a generalized tonic-clonic seizure
Case 1
• You have decided this is most likely a febrile
seizure.
• What do you do now?
DO
•ABC’s-recovery position, put nothing in mouth
unless it is for the airway, clear vomitus, jaw
thrust if necessary.
•O2 if needed (usually don’t need this, so it does
not need to be a priority)
DO
• Assess for shock / dehydration
• Check glucose OR consider empiric dextroseD50- treatment if no testing kit available
DO
• Assess—don’t panic—only treat with
medication if seizure lasts >5 min.
• Note if there are any localizing features
• You are once again prepared to do a physical
exam. What are the most important things
to do and document?
Physical exam
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Vital signs, Head Circumference
Level of consciousness.
Pupils and Cranial Nerves for palsy.
Fundoscopy for papilledema (discuss risks
associated with raised ICP).
• Meningeal signs are critical.
• Any focal neurological findings (need to
document tone, reflexes, Babinski).
Physical exam
• Pallor and cardiac gallop (malaria)
• Petechiae (meningitis)
• Spleen and liver enlarged?
Case 1
• Noy has a temperature of 40.2oC. HR 120. RR
28. You notice a II/VI systolic ejection
murmur along the left sternal border. There is
no gallop and she is not pale.
• She has not had another seizure
• What do you think about the murmur?
Case 1
• Heart murmurs—this is most likely a benign
flow murmur especially common in thin
children with fevers (to be sure, you must
check again when fever has gone down).
DDx
• Prepare a differential diagnosis for seizures in
a patient such as Noy based on what you
know.
• Comment on differentiating features.
Differential Diagnosis
• Febrile convulsion secondary to infection (viral, bacterial or
malaria)
• Meningitis
• Cerebral Malaria
• Seizure secondary to hypoglycemia (and possibly malaria)
• encephalitis,
• trauma,
• stroke/hemorrhage,
• poisoning
• metabolic encephalopathy,
• neurodegenerative disorder,
• brain tumor, neurocutaneous syndrome
• What is your problem list ?
Problem list
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Acute febrile seizure
? Infection—malaria vs meningitis vs other
Not immunized
Need for family counseling, what to do if
siezure recurs
• Heart murmur
• Orphaned
• Family history of non febrile seizure
• Which investigations would you consider?
Investigations
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Laboratory tests (such as CBC, Na+, K+, Ca++,
Mg++, glucose, and P04) depend on the
symptoms, seizure type, and history… if no
history of fever, must consider electrolytes
If a seizing febrile child has had several
episodes of vomiting and diarrhea, check
electrolytes, just as if the child had seized
without fever.
In the case of simple febrile seizures, routine
laboratory tests are usually not indicated.
Investigations
• The literature for tests for complex febrile
seizures is not as clear as those for simple
febrile seizures.
• Do consider laboratory tests in children who
present with complex febrile seizures.
• A child with fever may also have a known
seizure disorder, so check seizure medication
levels.
Fever without an obvious source
• Obtain a CBC and blood cultures
• Catheterized urine for urinalysis and urine
culture
• Stool culture for bacterial or viral enteric
infection, and shigellosis
• Nasal swabs for respiratory syncytial virus
(RSV) or influenza, if appropriate.
What about a lumbar puncture?
Indicators For Lumbar Puncture For
Evaluation Of Pediatric Febrile Seizure
• Recent doctor (or health care provider) visit for febrile
illness
• Less than 12 months of age*
• 12 months to 18 months of age*
• Altered mental status
• Prolonged post-ictal period
* If the child returns to normal (ie, normal neurological
examination, appears happy, nontoxic, etc.) in a case where
meningitis is considered unlikely, some literature suggests
that an LP is not strongly indicated in the routine evaluation
of a febrile seizure
Indicators For Lumbar Puncture For
Evaluation Of Pediatric Febrile Seizure
• Signs of increased intracranial pressure (ie,
bulging fontanelle)-if considering meningitis
• Kernig’s or Brudzinski’s sign
• Increased irritability
• Petechiae
• Recurrent seizures, seizures in the Emerg Dept
• Recent antibiotics
Case 1
• Prepare a brief treatment plan based on your
problem list
Case 1
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Airway
Breathing (O2 if necessary)
IV access for hydration,
Antipyretic: acetominophen
Bloodwork (glucose, Na, K, CBC, blood cultures,
urinalysis, urine culture)
• Antibiotic (+/- steroids)
• + / - LP
• ? Antimalarials
• Noy recovers thanks to your fine management
• Discuss what information you will give her
grandfather : chance of recurrence, what to
do at home, when to bring her to hospital
again
Facts: Febrile Seizures
• 3mo - 5yr
• Single, brief, occurs during rapid rise of fever
>38C, but without evidence of intracranial
infection or defined cause
• Generalized seizure / Not focal
• Normal child neurologically both before and
after seizure
Facts: Febrile Seizures
• Called “complex” febrile seizure if lasts longer
than 15min, is focal, or recurs within 24h
(although this seems common with malaria)
• Complex seizures have an increased risk of
meningitis (9%), compared to simple febrile
seizure (3%)
• Many children will have a positive family
history of febrile seizure and recurrence is
high (about 1/3)
Facts: Febrile Seizures
• There is no strong evidence that giving
antipyretics in the absence of Anti Epilepsy
Drugs (AED) can prevent recurrent febrile
seizures.
• AEDs are not routinely recommended for the
chronic prevention of febrile seizures.
Facts: Febrile Seizures
• Children with febrile seizures have only a 1-2%
chance of developing lifetime epilepsy,
compared to only a 0.5 - 1% risk in other
children
• Unless there are 2 or more risk factors (such
as family history of epilepsy, neurological
condition or disorder, or complex seizure),
then the risk for epilepsy jumps to 10%
Facts: Febrile Seizures
• 33% of children who experience a febrile
seizure will experience a second febrile seizure
• Peak incidence of febrile seizures occurs at
about 18 months of age
Case 2
• A 4-year old boy is brought to see you by his
parents. 5 minutes ago he started having a
generalized tonic- clonic seizure. There was
no preceding trauma. Prior to the seizure, the
parents describe that the boy was vomiting
and was talking funny.
Case 2
• On exam the boy is having a generalized tonic
clonic seizure. He is not responding to verbal
or painful stimulation.
• HR 140, BP 70/40, RR 20, O2 sats 96%. His
temperature is 37.8C.
• His pupils are dilated bilaterally and reactive
to light. He is hyper-reflexic. Normal
cardiovascular, respiratory and abdominal
exam.
DO
•ABC’s-recovery position, put nothing in mouth
unless it is an airway, clear vomitus, jaw thrust
if necessary.
•O2 if needed (usually don’t need, so this does
not need be a priority)
How would you manage this child?
Manage seizure once ABC’s taken care of
DO
• Assess for shock / dehydration
• Check glucose OR consider empiric dextroseD50- treatment, if no testing kit available
Management
• Check chemstrip….BG 12
• IV fluid bolus
• Treat the seizure
DO
• Diazepam 0.3 mg/kg IV. May be given x 3
doses, 5 minutes apart if seizure not
subsiding, maximum per dose 10 mg
• Per Rectum(PR) Child 2 - 5 years: 0.5 mg/kg
• PR-Child 6 - 11 years: 0.3 mg/kg
• PR-Child > 12 years: 0.2 mg/kg, maximum per
dose 20mg
• The rectal route is useful when intravenous
access is unavailable.
DO
• Consider Phenytoin or Phenobarbital load
(Some prefer Phenytoin because less
depression of consciousness and less likely to
cause respiratory depression in combination
with diazepam, but difficult to attain
therapeutic levels)
• Loading dose Phenobarbital and Phenytoin
(10-15mg/kg) if seizure persisting
DO
• Watch carefully for respiratory depression
which can happen with either drug alone or
especially with the combination of diazepam
and phenobarbital
• Check blood electrolytes, glucose, CBC
Case 2
• The child’s seizure stops but he is still
obtunded and does not respond to
stimulation
• After 15 minutes, he has another seizure
What would you do now?
Case 2
• Recheck vitals
• Retreat as above
Differential Diagnosis
• What could be the cause of this child’s
seizures?
Differential Diagnosis
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Idiopathic
Meningitis
Cerebral malaria
Febrile convulsions
Hypoglycemia
Hyponatremia
Head injury
Brain tumor
Poisoning
Shock
Case 2
• Once you have the seizures under control, you
must talk to the parents.
• They tell you this is the third time the child
has had seizures in the past 3 months.
• What advice do you give them now?
Epilepsy
• Tell them their child likely has Epilepsy—most
often begins in childhood
• Risk factors include previous seizure (febrile or
non), family history, cerebral palsy
• If a child has 2 or more unprovoked seizures or
1 unprovoked seizure with an abnormal EEG,
then a definition of epilepsy can be made and
appropriate Anti-Epilepsy Drugs started
Epilepsy
• Is a diagnosis of exclusion or pattern
recognition—rule out brain tumour, infection,
injury, neurocutaneous disease, syncope,
hypoglycemia, hypocalcemia, breath-holding
spells, drug-induced movement disorder.
• An EEG would be the best test to do in a normally
developing child.
• If the child had abnormal development, you
might consider imaging the brain, if it is available.
Epilepsy
• Medication is required if there are recurrent
seizures
• Phenytoin or Phenobarbital are the usual
medications used first
• Both have side effects
• There are many new seizure medications now.
May not be available in Laos, or affordable.
Epilepsy
• Seizure management at home:
- Don’t panic
- Place in recovery position to avoid aspiration
- Place nothing in mouth.
- Bring to medical attention if seizure is
persistent (>15 min) or if frequency increases
Epilepsy
• Risk of mortality by drowning (while
swimming or bathing) and burns (falling into
fires)—therefore child must be carefully
supervised.
• Keep all antiepileptic drugs in a safe place.
• May discuss stigma of epilepsy—school,
community, traditional beliefs
• ***see appendices for more information
Case 3
• An 11-month old presents to your emergency
room. He has been seizing for 30 minutes,
generalized tonic- clonic movements. He is
slightly cyanosed and unresponsive.
• The nurse puts him on a bed on his back, and
leaves the room, telling his parents to watch
him.
• She finds the doctor and tells him there is a
sick child in the room, then leaves to eat.
Case 3
• The doctor finishes his chart, then goes to the
room to find the child in a pool of vomit,
choking, and very blue.
• His parents say they are afraid to touch him,
because the nurse told them to watch him.
Case 3
• What do you do now?
Case 3
• What steps could be taken in your
hospital/office to ensure better care of this
kind of patient in the future?
Pre-Test
1) What is the most common cause of childhood
seizures?
a) poisoning
b) birth trauma
c) fever
d) head trauma
Pre-test
2) What drug should you use to stop a seizure
that has lasted 4 minutes?
a) phenobarbital
b) diazepam
c) phenytoin
d) don’t treat unless seizure has lasted at least
five minutes
Pre-test
3) When a child has a seizure, when is a lumbar
puncture indicated?
a) In every case
b) Only if there are signs of increased intracranial
pressure
c) If there is fever and neck stiffness, and
meningitis is being considered.
d) If the child has a red throat
Pre-test
4) What is the first thing you do when
confronted by a seizing patient?
a) ABC’s , recovery position, glucose
b) Draw blood for electrolytes and glucose
c) Administer bicarbonate to counteract
metabolic acidosis
d) Observe to see how long the seizure is going
to last
Pre-test
5) What is the most important part of chronic
seizure management in children?
a) Use of two medications for seizure control
b) Discovering the family’s knowledge level and
educating them as much as possible about the
seizures and what to do.
c) CT scan of the brain
d) Educate the community about the seizures
e) b and d
Appendices
• Information about seizures
Seizure types
• Seizures can be divided into generalized or
partial types.
Generalized seizures
• Generalized seizures are associated with the
involvement of both cerebral hemispheres
and can be convulsive or nonconvulsive.
• Motor involvement, if present, is most often
bilateral.
• An altered level of consciousness can be
present with generalized seizures
Partial seizures
• Partial seizures can be simple or complex.
• A partial seizure is defined as a focal event.
• Simple partial seizures result in no impairment
of consciousness; clinical localization of
epileptic focus is possible.
• The twitching of an arm in an awake patient is
an example of a simple partial seizure.
Complex Seizures
• A complex seizure is a partial seizure
associated with loss of consciousness.
• Complex seizures can be preceded by an aura
and are associated with certain automatisms
(patient is not aware of his surroundings while
doing some unusual movements ).
• In 30% of children with either simple or
complex partial seizures, the child can
progress to having generalized seizures.
Special Seizures
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Febrile Seizures
Neonatal seizures
Infantile Spasms
Autonomic Seizures
Lennox Gastaut Syndrome
Benign Rolandic epilepsy
Epidemiology
• Childhood seizures are common (4-6% of
children)
• Seizure is a symptom of an underlying
disorder, not a disease in itself
• Fever is the most common cause of a seizure
in a child.
Medications Used For Acute Seizure
Management
Medication
Diazepam
Suggested Doses
IV 0.3 mg/kg, maximum per dose 10mg
PR Child 2 - 5 years
0.5 mg/kg
PR Child 6 - 11 years 0.3 mg/kg
PR Child > 12 years 0.2 mg/kg, max /dose 20 mg
Lorazepam
IV 0.05 – 0.1 mg/kg, maximum per dose 4 mg
IM 0.05 – 0.1 mg/kg, maximum per dose 4 mg
Midazolam
IV 0.15 to 0.2 mg/kg, followed by 0.5 –5mcg/kg/min
continuous infusion
Buccal 0.2 – 0.3 mg/kg
Intranasal 0.2 mg/kg
Medications used for Acute Seizure
Management
Phenytoin
Fosphenytoin
IV 15 – 20 mg/kg
IV 15 – 20 mg PE/kg
IM 15 – 20 mg/kg
Phenobarbital IV 20 mg/kg
Pentobarbital IV 5 – 15 mg/kg, followed by 0.5 – 5
mg/kg/h continuous infusion
Valproic acid
IV 20 – 40 mg/kg
Levetiracetam IV 20 – 115 mg/kg/day
Propofol
IV 1 – 2 mg/kg followed by 1 – 2
mg/kg/h
continuous infusion titrated
to burst
suppression on the EEG
VITAMIN C,D,P
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M
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C
D
P
vascular, hematologic
infectious, inflammatory, intoxication
trauma, toxin
allergic
metabolic, endocrine
immunologic, autoimmune
neoplastic, neurologic, nutrition
congenital, genetic
degenerative, drugs
psychiatric
Poisonings that can cause seizures
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ASA (aspirin)
INH (isoniazid)
Tricyclic antidepressants
Propranolol
Lithium
Hydrocarbons (camphor, toluene, phenols,
chlorinated)
• Antihistamines