CONVULSIONS AND STATUS EPILEPTICUS.pptx

How to diagnose subtle convulsions in children

1. CONVULSIONS AND STATUS EPILEPTICUS By: LWANGA HERBERT FELIX UWERA BENITAH Tutor: Dr. Kalubi Peters 10/17/2023 1

2. Tutorial Outline Definitions Neuro -anatomy & physiology of normal consciousness Vs Coma Conditions that mimic Coma Coma Etiologies Coma Assessment scales (GCS, BCS, AVPU) Approach to a convulsing/ Comatose child i.e Hx and P/E Investigations Management of a convulsing child & Status epilepticus 10/17/2023 2

3. DEFINITIONS Seizure : Abnormal excessive electrical firing, or neuronal activity in the brain which may result into motor(contraction of muscles) or non motor(such as loss of awareness, incontinence, drooling, yawning among others) results 10/17/2023 3

4. seizures It can either be epileptic OR non-epileptic Epileptic : manifestation due to abnormal synchronous neuronal activity in the brain Non-epileptic seizure : mimics seizures but have nothing to do with the brain, e.g. Shivering 10/17/2023 4

5. 2. Fit: Abnormal electrical activities in the brain that occur quickly and can go almost unnoticed. 3. Spasm: A sudden involuntary muscle contraction. 4. Convulsions: Motor manifestation of a seizure. Can be classified into Generalized: Tonic : Extension Clonic: Flexion Tonic- clonic : Both extension and flexion Myoclonic: Localised to muscle Atonic: Loss of tone, can lead to sudden falls 10/17/2023 5

6. Focal Either motor, or non-motor Coma: Prolonged state of unconsciousness in which a person cant be awakened and is unresponsive to stimuli ( e.g light, pain, sound) and lacks a normal sleep-wake cycle, and doesn’t initiate voluntary actions. Epilepsy: A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness/ convulsions due to abnormal electrical activity in the brain. I t needs at-least 2 unprovoked seizures occurring more than 24hrs apart. 10/17/2023 6

7. Status epilepticus: An afebrile seizure lasting more than 15 minutes, or Recurrent seizures lasting in total more than 30 minutes without return to consciousness in between. Febrile Convulsions: A seizure of infancy/ childhood (1 month- 5yrs) associated with fevers but without evidence of intracranial infection or a defined cause ( such as trauma) 10/17/2023 7

8. Febrile Convulsions : convulsions precipitated by fever, not due to an intracranial infection or other definable CNS. Features: Fevers >38 ℃ No neurological abnormality in the period between episodes Usually brief convulsions and benign Age dependent and occur between 6months and 5years of age. Types Simple Febrile convulsions (85%): Brief Generalized tonic- clonic seizure lasting a few seconds to a few minutes, usually < 5mins followed by full recovery, and don’t go beyond 15mins. Don’t recur within 24hrs. Complex/Atypical Febrile Convulsions(15%): prolonged (> 15mins)repeated convulsions occur within the same day ( reccur more than once within 24 hours), when the seizure is focal( confined to one side of the body ) or post-ictal focal deficit noted. 10/17/2023 8

9. Prognosis: Simple Febrile Convulsions: low risk of epilepsy(1%), no adverse effects on behavior/ neurocognition Complex febrile convulsions : Increased risk of epilepsy and this may also be associated with other risk factors such as a positive family history of epilepsy, an initial febrile seizure before 9months of age, delayed developmental milestones or a preexisting neurological disorder. 10/17/2023 9

10. Neuro -anatomy & Neuro physiology of Normal conscious VS Coma Coma : The patient cannot be aroused, and the eyes are closed and do not open in response to any stimulation. Maintaining alertness requires intact function of the cerebral hemispheres and arousal mechanisms in reticular activating system(RAS-also known as the ascending arousal system)- an extensive network of nuclei and interconnecting fibers in upper pons, mid brain and posterior diencephalon. Therefore, the mechanism of impaired consciousness must involve both cerebral hemispheres or dysfunction of the RAS 10/17/2023 10

11. To impair consciousness, cerebral dysfunction must be bilateral; unilateral cerebral hemisphere disorders are not sufficient, although they may cause severe neurologic deficits. However, rarely, a unilateral massive hemispheric focal lesion( e.g left middle cerebral artery stroke) impairs consciousness if the contralateral hemisphere is already compromised or if it results in compression of the contralateral hemisphere(such as by causing oedema.) 10/17/2023 11

12. Usually, RAS dysfunction results from a condition that has diffuse effects such as toxic or metabolic disturbances ( such as hypoglycemia, hypoxia, uremia, drug overdose). It can also be caused by focal ischemia(such as certain brainstem infarcts), hemorrhage or direct mechanical disruption. Any condition that increases the intracranial pressure may decrease cerebral perfusion pressure, resulting in secondary brain ischemia. Secondary brain ischemia may affect the RAS or both cerebral hemispheres, impairing consciousness. 10/17/2023 12

13. Conditions that may mimic Coma Locked-in-syndrome: A rare neurological d/o in which there is complete paralysis of all voluntary muscles except those controlling eye movements Hypersomnia such as Narcolepsy Akinetic mutism: Syndrome characterized by marked reduction of nearly all motor functions including facial expression, gestures & speech output, but with some degree of alertness (can be due to stroke ) Persistant vegetative state 10/17/2023 13

14. Etiologies of Coma Infections: Meningitis, encephalitis, sepsis, CCM, CMV, HSV, toxoplasmosis Metabolic disorders: DKA, Hypoglycemia, hypothyroidism, Electrolyte imbalances such as hypercalcemia. Toxins Intrinsic such as Urea due Kidney failure, NH4, CO2 Extrinsic such as Alcohol, CO, Drugs like opioids, anaesthetics, sedatives Traumatic: Head injury, Space occupying lesions (abscesses , tumors) Hypoxia 10/17/2023 14

15. Coma Assessment Scales Glasgow Coma Scale 10/17/2023 15

16. 2. Modified GCS 10/17/2023 16

17. 3. Blantyre Coma Scale 10/17/2023 17

18. 4. AVPU 10/17/2023 18

19. Clinical history in a coma/ convulsing child Onset of symptoms (gradual/acute) Any vision problems/dizziness/stupor / numbness prior Any chronic disease such as DM, HTN History of seizures/ stroke Any chronic medications Hx of fever to rule out cerebral malaria Hx of yellowing eyes to rule out kernicterus Time of last meal to rule out hypoglycemia High pitched cry to rule out meningitis Hx of trauma to rule out TBI Hx of confusion to rule out electrolyte imbalances 10/17/2023 19

20. Approach to Physical Examination For a convulsing child, do a detailed general exam, and systemic exams General exams Vitals: Temp, RR, SPO2, PR, GCS/BCS/AVPU Note: BP & HR very crucial in syncopy Febrile, jaundice, pallor, etc + pigmentation e.g in neuro -cutaneous syndromes, etc b) Systemic exams, e.g GIT, RS, CVS, and a Focused Neurological Exam (Cranial nerves & Motor and Brainstem reflexes e.g Corneal, Dolls reflex, oculovescular reflex) 10/17/2023 20

21. Brainstem reflexes Absence of: Pupils: no response to light Cornea: no corneal reflexes Oculocephalic testing (head turning) and oculovestibular (caloric) testing Motor response to adequate somatic stimulation within distribution of cranial nerve Gag reflex( pharyngeal and tracheal reflexes) NB: Brainstem reflexes are usually used in assessing brainstem death(if they are absent) 10/17/2023 21

22. Investigations Based on patient’s presentation. Note: commonest cause of coma and convulsions in children is Cerebral Malaria Investigations include, but not limited to: RBS Blood smear for malaria/ mRDT CSF Analysis/ culture, Blood culture, Serum electrolytes EEG Neuroimaging e.g CT/ MRI CBC 10/17/2023 22

23. LOGICAL INVESTIGATION APPROACH Random Blood Sugar. Blood smear Lumbar puncture for CSF analysis/ Blood culture Metabolic screen Imaging such as Cranial ultrasound on the anterior fontanelle, CT scan. 10/17/2023 23

24. Management (Convulsing child & Status epilepticus ) Seizures in children usually <3mins, however if >5mins=Prolonged seizures, and these have more likelihood to injure brain. Status epilepticus is an Emergency 10/17/2023 24

25. Active Management Ensure safety (patient and co.) space,remove tight clothes Left lateral (recovery)position ABC(Airway patency, Breathing, & Circulation) AVOID Restraining patient, putting anything in the mouth, even feeds during an episode Arousing convulsing child Leaving convulsing pt unattended to before recovery Time episodes where possible 10/17/2023 25

26. If prolonged seizure (>5min) Initiate active pharmacological mgt First line: Benzodiazepines (Diazepam/Midazolam) IV, or rectal. IV Diazepam 0.3mg/kg (S.Es Resp arrest) If 1 st dose doesn’t work in 10 mins , give 2 nd dose of diazepam. If it doesn’t work, switch to 2 nd line 10/17/2023 26

27. Second line: These are longer acting anti-epileptics e.g Phenobarbital & Phenytoin Phenobarbital (10-15mg/kg slowly and monitor vitals) If this doesn’t work, inform ICU who’ll do general anaesthesia and mechanical ventilation (3 rd Line) 10/17/2023 27

28. References Uganda Clinical Guidelines 2016 WHO Pocket handbook of paediatrics ILAE 10/17/2023 28

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