Transcript Seizure recognition, seizure types, First Aid and Safety

SEIZURE RECOGNITION, SEIZURE
TYPES, FIRST AID AND SAFETY
Charuta Joshi MBBS, FRCPC
Director of pediatric epilepsy
UIHC
Objectives
At the end of this lecture the participants will be able to:
Define a seizure
Recognize different types of seizures
Define epilepsy
Know basic steps involved in seizure first aid
Name 2 different medications used on the site to treat seizures in the
prehospital setting
Be familiar with ketogenic diet as therapy for seizures
What is a seizure
Seizure recognition
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A clinical manifestation of :
Abnormal
Excessive
Paroxysmal
Electrical discharge in neurons
Seizure recognition
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Stereotyped
Repetitive
If unsure video tape events
Ask pediatrician to see
Seizure recognition
• Spectrum of findings
Generalized seizures
Complex partial seizures
Simple partial
seizures
Seizure recognition
simple partial seizures
• Localization
Seizure recognition
Generalized
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Absence
Myoclonic
Tonic
Generalized tonic clonic
How important is it to be sure about a
seizure
First seizure clinic results
• 127 children
• 94 were given diagnosis of epilepsy in first
seizure clinic
• 36 had suffered at least one previous seizure
( 15 unrecognized by family as a seizure)
• 31 – non epileptic events
• Unclassified in 2
Differential diagnosis
Investigations after a first unprovoked
seizure
Investigations
Yield of neuroimaging
(Shinnar et al 2001)
What is epilepsy
• Tendency to have recurrent, unprovoked
seizures
• 2 or more unprovoked seizures separated by
24 hours
Questions parents have after seizures
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Will it happen again?
How long do I have to wait for a recurrence?
Could my child die during a recurrence?
Could there be brain damage due to
recurrence
• If medication treatment is delayed will there
be change in long-term chance of permanent
remission?
Recurrence risks
• Recurrence rate at 2
years 40-50%
• Half the recurrences are
within 6 months of
initial seizure
• 80% of 5 year
recurrence risk
stabilizes by 2 years out
Risk factors for recurrence
• Remote symptomatic etiology
• Abnormal EEG ( any spikes, generalized spike wave,
focal or generalized slowing)
• Occurrence of seizure during sleep state (increases
chance of recurrence)= lower morbidity than during
daytime seizure
• Risk of recurrence after 2 seizures is 80%
Do you treat a first seizure
• Treatment reduces the risk of a second seizure
by 50% at 2 years
• Immediate treatment DOES NOT reduce risk of
long term seizures
• Treated and untreated groups have a 64%
chance of 5 year remission at 10 years (MESS
study)
• Risk of toxicity, allergic reaction, cognitive side
effects
Risks of morbidity/ mortality due to
seizures- could my child die??
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692 children in Nova Scotia ( Camfield 2002)
Followed =20 years
26 deaths
1 from status
1 from SUDEP as an adult at age 22 years
Could my child die
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Dutch study of childhood epilepsy ( Callenbach 2001)
472 children followed for 5 years
9 deaths
None from epilepsy
Connecticut study ( Berg 2004)
613 children followed for 7.8 years
13 deaths
1=status
1=SUDEP
When does immediate treatment
matter
• When risks of recurrent seizures outweigh
benefits of withholding treatment ( adults)
• Cyanotic congenital heart disease in a child
Seizure first aid
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ABCs
Stay calm
Don’t leave patient alone
Lateral position if possible
Don’t restrain
Nothing in mouth
Call 911
Seizure safety
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Maximize quality of life
Water safety
Safety on roads
High structures
Medic alert, seizure beds, seizure dogs, baby
monitors
Seizure precautions
• Regular sleep
• Alcohol
• Infections
• Photic stimulation
• Substances of abuse
Sports participation has not been shown to
increase risk of seizures
Prehospital treatment of seizures
Operational
definition of
status
Most seizures
stop
0
Time definition of
convulsive status
epilepticus
Optimum time to
start therapy
5
15
30
Medications used for prehospital
treatment
• Diazepam
• Midazolam
• Lorazepam
Prehospital treatment
midazolam
Lorazepam
• 2mg/ml Intensol
• Indicated for anxiety
Faves…
Moving on to a different
discussion now…
Ketogenic diet
• UIHC= The only center in the state
• 30-40 active patients
• Dedicated dietician
Karla Mracek
• Dedicated ARNP
Tiffany Rickertsen
Historical anecdotes
History
• Mac Fadden 1899- magazine
Physical Culture
• Medical profession= Organized
fraud
• People who follow MacFadden’s
rules would live to 120 years
• Since much of the body’s energy
is wasted in digesting food, if no
food is provided, more energy
can be applied to recovering
health
• Dr Conklin-osteopath in
Battlecreek , Mi
• Used diet in epilepsy
Mr MacFadden
• Physical culture
Historical anecdotes
• Conklin’s work( intestinal epilepsy- toxin
release from glands= seizures)
• Conklin’s fast 18-21 days ( or as long as they
could stand it)
Historical anecdotes
• Dr Geyelin worked at Johns Hopkins=
confirmed Conklin's findings
• Dr BJ Wilder= fat can be used to break fast=
no seizures
Charlie foundation
Charlie Foundation
• Mr Jim Abrahams
• Sought help from Johns
Hopkins for his son Charlie
• Seizure free today after
several medications and
neurologists
Movie
Since then…
Indications
Mechanisms of action
Not exactly known
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Ketone bodies= antiepilepsy properties
PUFAs= membrane stabilization
Antioxidative/ antiinflammatory
Uncoupling of oxidative phosphorylation(
better energy utilization)
Types of ketogenic diet
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Classic ketogenic diet= 4:1 ratio
MCT oil diet ( less restrictive)
Modified Atkins diet=15-20 gm carbs/day
Low Glycemic index diet=60 gm carbs/day
Ketogenic diet
Most kids not fat…
Results
• 50-60% improve
• Almost 100% improve –
Doose , GLUT1
Contraindicated
Fatty acid oxidation defect
Thank You !!