pediatric convulsion

1. convulsions in children Prepared by: ANCY ANTO M.Sc . Nursing

2. History... 3000 yrs ago ......Babylonians wrote about the symptoms and causes of epilepsy caused by demons attacking the person The word epilepsy is derived from the Greek word for "attack’’

3. Patron of epilepsy......... St.valentine

4. World epilepsy day National epilepsy day November 17

5. Did you know that: Epilepsy is not a form of mental illness Epilepsy can begin at any age from birth to 99+ Epilepsy can & does affect memory and learning. NOTHING should be put in the mouth of a person having a seizure

6. Medication does not stop all seizures . Epilepsy is not contagious The tongue cannot be swallowed during a seizure Most seizures are not medical emergencies

7. Seizures... It is a transient occurrence of signs and / or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain A sudden paroxysmal electrical discharge from the CNS resulting in involuntary motor, sensory or autonomic disturbances with or without alteration in sensorium

8. Epilepsy.... Is a disorder of the brain characterised by an enduring predisposition to generate seizures & by the neurological cognitive, psychological & social consequences.

9. Epileptic syndrome.. Is a disorder that manifests one or more specific types and a specific age of onset and a specific prognosis.

10. Disorders mimicking seizures... Jitteriness Benign neonatal sleep myoclonus Breath holding spells Shuddering attacks Syncopal attacks Night terror pseudo seizures

11. Provoked vs. Unprovoked seizures.. Provoked = occurs during the course of acute illness Common causes Febrile seizures Metabolic events (b. sugar <36mg/dl) Acute CNS infections Drug intoxification Head trauma

12. Incidence 72-80 / 1lak under 9 yrs of age 46-83 / 1lak under 14 yrs of age Prevalence Seizure disorders: 360/100,000 (India, Saha SP 2003). 350/1lak in India Greater in neonatal period

13. Classification of Epileptic Seizures. Partial seizures: Simple partial (consciousness retained) Motor Sensory Autonomic Psychic Complex partial (consciousness impaired) Simple partial, followed by impaired consciousness Consciousness impaired at onset Partial seizures with secondary generalization

14. Generalized seizures Absences Typical Atypical Generalized tonic clonic Tonic Clonic Myoclonic Atonic Infantile spasms Unclassified seizures

15. ILAE classification Self limited Focal Generalised Continuous Classification of epilepsy syndromes Idiopathic-focal & general Familial Symptomatic reflex

16. Common causes Infection to the central nervous system 1. Acquired bacterial meningitis tuberculus meningitis aseptic encephalitis cerebral malaria 2. Intrauterine infections

17. Post infectious or post vaccinal encephalopathy Pertussis vaccination Pan encephalitis Post measles encephalopathy Chickenpox encephalopathy Disseminated encephalomyeolopathy

18. Metabolic causes Dehydration Dyselectrolytemia Acidosis/ alkalosis Hypocalcaemia/ hypomagnesaemia Inborn errors of metabolism

19. Space occupying lesions in the brain Neoplasm Brain abscess Tuberculoma Cysticercosis

20. Vascular Arterio venous malformations Intracranial thrombosis/ haemorrhage Coagulopathies Congenital malformations Migration defects

21. Miscellaneous Birth trauma Birth asphyxia Heat stroke Brain swelling Poisoning Lead encephalopathy Breath holding spells Gray matter degeneration

22. Drugs and poisons Toxic doses of phenothiazine Salicylate Diphenylhydantoin Carbon monoxide

23. Causes Early neonatal period Neonatal period 1m - 3 yrs Birth asphyxia Obstructed labour IVH Hypoglycaemia IEM Hypocalcaemia Kernicterus Developmental malformations Meningitis Metabolic errors Febrile convulsions Neurologic infections Metabolic causes Lesions drugs

24. Mechanisms of seizure Underlying aetiology Epileptogenesis Excitability Neuronal injury after prolonged febrile & afebrile status epilepticus

25. Neuron – action potential

26. Basic mechanisms of epileptogenesis

27. Neurophysiology and neurochemistry Epileptogenic neurons + disinhibition + circuit PDS trigger Ca channel (Mg) synchronization Opens sp. K+ channel Hyperpolarisation

28. Hyperpolarisation Disappear depolarisation seizure

29. Kindling Process by which brief trans of electrical stimuli are repeatedly delivered at appropriate intervals to a susceptible area of brain. Prolonged generalised seizure

30. Factors determine focal – generalised Excitability of epileptic neurone The ease with which the electric discharge can be propagated from focus Threshold of brain stem for disseminating an electrical discharge

31. Excitatory & inhibitory neurotransmitters Glutamate & aspartate – Excitatory neurotransmitters Induces Ca + ion current Depolarisation seizure

32. Inhibitory neurotransmitters GABA Hyperpolarisation GABA receptors are coupled with Cl - channel stabilises cell in resting potential Pyridoxine deficiency Adenosine- inhibit the release of excitatory neurotransmitters

33. Catecholamine's & indolamines ↓ in nor epinephrine -↑ seizure susceptibility ↑ in nor epinephrine- ↓ seizure severity

34. Biochemical alterations induced by seizure

35. epilepsy syncope Precipitating factors Occurrence Onset Duration Jerking limbs Facial colour Perspiration Post ictal recovery Post ictal confusion EEG & prolactin Rare Awake , sleep Abrupt 60-90 sec Yes Flushed Hot, sweaty Slow Common Positive Common Awake Gradual 10-15 sec Occasional Pale Cold , clammy Rapid Uncommon Negative

36. Partial seizures. Simple partial Localised motor symptoms Somatosensory, psychic, autonomic symptoms Manifestations - aversive seizure- eyes and head turn away from focus & loss of consciousness - rolandic seizure - tonic– clonic movements involving face, salivation, arrested speech

37. Jacksonian march Sequential progression of Clonic movements

38. Simple partial seizures with sensory signs.. Numbness Tingling Pricking Paresthesia/ pain originating in one area Visual sensations Motor phenomena – posturing / hypertonia - Uncommon < 8yrs

39. Complex partial seizures(psychomotor seizures) 3yrs – adolescence Characterised by Period of altered behaviour Amnesia Inability to respond to environment Impaired consciousness during event Drowsiness / sleep Confusion & amnesia

40. aura odd or pleasant odours Auditory or visual hallucinations Ill defined feelings (de javu) Strong feelings of fear and anxiety In small children - emission of cry - attempt to run

41. Patterns of motor behaviour Stereotypic May suddenly cease activity , appear dazed stare into space Confused & apathetic Become limp or stiff automatisms Post ictal confusion

42. Exhibit oropharyngeal activities –smacking chewing , drooling etc Rarely exhibit – temper tantrums or rage

43. Generalised seizures Tonic clonic seizures ( grandmal ) Most common Occur without warning Tonic phase clonic phase post ictal phase

44. Tonic phase 10- 20 sec Eyes roll upward Immediate loss of consciousness Stiffness Contraction of entire body Arms flexed Legs, head & neck flexed

45. May utter a peculiar cry Apnoeic Increased salivation Loss of swallowing reflex If standing, falls to floor or ground

46. Clonic phase 30 sec Violent jerking movements Foams at mouth Incontinent of urine and faeces

47. Post ictal state Appears relaxed Remain semiconscious May awake in few minutes Confused for several hours Poor coordination Mild impairment in fine motor movements

48. Visual & speech difficulties Vomit or complain of severe headache Usually sleeps for several hours Feels tired No recollection of event

49. Absence seizures (petit mal/ lapses) 4-12 years of age common in girls than boys Ceases at puberty Brief / no loss of consciousness No alteration in muscle tone May go unrecognised Abrupt in onset

50. Manifestations: Brief loss of consciousness Without aura 5-10 sec Slight loss of muscle tone Minor movements No incontinence Amnesia Need reorientation

51. Atonic & akinetic seizures (drop attacks ) 2-5 yrs Sudden momentary loss of muscle tone & postural control Recurrent frequently Manifestation : - Loss of tone causing child to fall down

52. Myoclonic seizures Seizure episodes Sudden brief contractions of a muscle No post ictal state May / not LOC

53. Infantile spasms Infantile myoclonus / massive spasms / hypsarrhythmia / salaam episodes / Infantile myoclonic spasms 6- 8 months of life Twice common in boys Numerous without post ictal drowsiness

54. Manifestations Series of sudden muscular contractons Head flexed arms extended & legs drawn up Eyes rolling Preceded / followed by cry May / not LOC Flushing / pallor / cyanosis

55. Jack-knife seizure – sudden dropping forward of the head & neck with trunk flexed forward Single momentary shock like contractions

56. Comparison of simple, complex partial & absence seizure Clinical features Simple complex Absence Age of onset Any age Uncommon before 3 yrs Uncommon before 3 yrs Freq /day Variable 1- 2 times Multiple Duration < 30 sec >60 sec <10 sec Aura May be sole manifestation Frequently never Impaired consciousness Never always Always Automatisms never frequent frequent

57. Clinical features Simple complex Absence Clonic movements Frequent Occasional Occasional Post ictal impairment Rare Frequent Never Mental disorientation Rare Common Unusual

58. Video game related epilepsy Flicker frequency of video games Type – generalised , simple / complex / absence Treatment – abstain from video games Factors – screen brightness, sleep deprivation, fatigue, fever, short distance from screen

59. Epilepsy syndromes The Major Benign Partial Syndromes 1. Benign Rolandic Epilepsy - Male preponderance 60% Onset 2 - 13 years (peak: 9-10 years) Older children- motor & somatosensory symptoms, usually nocturnal.

60. Younger children- Hemiclonic / GTCS (especially at night). Rx: None if seizures are mild and rare. Most AEDs very effective. Evolution: Recovery before 15 - 16 years.

61. Benign Occipital Epilepsy Frequency- rare Genetic 37%, migraine 17% Male = female Onset 2 - 17 years (peak:7 - 8 years)

62. Initial visual symptoms, often followed by a hemiclonic seizure or by automatism Postictal migrainous cephalgia in a quarter of the cases. Rx: Most AEDs with control in 60%. Recovery by end of adolescence.

63. The Major Primary Generalized Syndromes Childhood Absence Epilepsy (True Petit Mal Epilepsy) Frequency 8% Genetic predisposition- strong 20% Female preponderance 75% Onset 3 - 12 years (peak: 6 - 7 years) Very frequent simple absences .

64. Rx: VPA or ESM with control in 70 - 80%. Evolution : Remission- 95%. - Rare persistence of absences only- 6%. - GTCS during adolescence or later- 40%.

65. Juvenile Myoclonic Epilepsy (JME) Frequency 5% Genetic predisposition- strong >25% Male = female Onset: 8-26 years (peak: 16 - 17) Myoclonus , GTCS often also occur, occasionally absence. Rx: VPA with control in 60 - 100% Evolution: Rarely remits (<10%)

66. Grand Mal on Awakening (GMA) Genetic predisposition- strong >10% Male > female Onset 6-24 (peak: puberty) GTS exclusively or predoninantly (90%) Myoclonic or absence may occur. Rx: VPA with control in 60 - 100% Evolution: Rarely remits (<20%)

67. The Major Secondary Generalized Syndromes Infantile Spasms (West Syndrome) Lennox Gastaut Syndrome (LGS) Frequency 3 - 10% Genetic predisposition- no Male preponderance Onset 1 - 8 years (peak: 3 - 5 years)

68. Poor prognosis in most cases Tonic, atypical absence, drop attacks, other generalized or partial seizures. Rx: VPA,rarely with complete control. persisting seizures.

69. DIAGNOSTIC EVALUATION History collection Physical examination Laboratory investigations Serum glucose & calcium levels Lumbar puncture – I st febrile seizures protein content – increased

70. Imaging studies: CT MRI- structural lesions PET-demonstrate perfusion,O 2 & glucose intake SPECT scan- perfusion in ictal & inter ictal state Cerebral angiography Magneto encephalography Telemetry

71. Electroencephalogram Electric activity of brain. Fast activity – beta rhythm(14 - 20 Hz) Alpha rhythm – 8 -13 Hz Theta rhythm – 4 - 7 Hz Slow rhythm- 1 - 3 Hz

72. Absence seizure

73. Abnormalities. Slow/ abnormal rhythm-generalised ,localised or lateralised to one side thus helps to anatomic lesions Spikes Sharp waves Poly spikes Slow waves (hypsarrhythmia)

74. Tests consider in the evaluation of patients with seizures Type Test Comments Simple partial Complex partial GTC Absences MRI MRI MRI None required Rule out structural lesions Rule out structural lesions Rule out structural lesions

75. Management of child with seizures Goals: Ensure adequate vitals & oxygenation Terminate seizure activity Prevent seizure recurrence Establish the diagnosis & treat the underlying

76. steps Step I – confirm diagnosis Step II – establish seizure type & syndrome Step III – evaluate the need for treatment Step IV – select AED Step V – start monotherapy (start slow go slow policy) Step VI – switch to another monotherapy add on therapy

77. Treatment of a newly diagnosed case of epilepsy Newly diagnosed case I st monotherarpy seizure therapy II nd monotherapy/ combination therapy seizure free Intractable epilepsy Combination therapy ketogenic diet , VNS

78. Choice of AED Seizure First line second line partial CBZ, PHT, SVA , PB OXC, LTG, TPM 2 nd gen GTCS SVA, ESM, CZP, CLB LTG , TPM , LEV GTCS SVA, CBZ, PHT, PB TPM, LTG, OXC, LEV Absence SVA , CZP, CLB LTG , TPM , LEV Myoclonic SVA LTG , TPM , LEV Atonic / tonic SVA CBZ, CLB , NTZ, LTG, TPM mixed SVA

79. ILAE GUIDELINE FOR DRUG LEVEL MONITORING Check compliance once or twice YEARLY Suspect toxicity after each AED change DURATION : Withdrawal – if seizure free for 2 YEARS Gradually over 6-12 wks

80. Ketogenic diet A very strict diet that involves fluid restriction, high fat and low carbohydrate + protein intake. The goal: alter the body’s fuel source from glucose to fat. The basis of the diet – fasting The encounter with a faith healer

81. Duration – 2yrs

82. Sample Meals: Meal 1: melted butter heavy whipping cream chicken apple sugar free Jell-O

83. Problems that may arise: Low blood sugar Lethargy Nausea Vomiting Elevated cholesterol Kidney stones Constipation Weight loss or gain Dehydration Cheating

84. Vagus nerve stimulation >12 years 50% reduction in seizures

85. Types of surgery 1. Resection Removal of the area causing the seizures 2. Disconnection Corpus callosotomy Multiple subpial transections 3 .Hemispherectomy

86. procedure Type Temporal lobectomy nonTemporal lobectomy Corpus callostomy Hemispherectomy Simple/ complex partial Partial Partial, tonic ,clonic Unilateral , partial , hemiparesis

87. Nursing management Seizure precautions Relieving anxiety Managing treatment Providing family support & education

88. Febrile seizures Occurrence of seizure activity in neurologically healthy infants & children between 6 months & 5 yrs of age associated with fever >38c without evidence of intracranial infection & with no history of prior afebrile seizures

89. Common in 18- 22 months Provoked seizures Causes: Infections of middle ear URTI Urinary tract & GI infections

90. Types Simple febrile seizures : 85% Generalised seizures Lasting less than 15 min No post ictal neurologic abnormalities

91. Complex febrile seizures - Recurrent within 24 hrs Febrile status A seizure with duration of 30 min Without regaining consciousness interictally

92. Risk factors Age <18 months Family history Shorter duration Recurrence 75% within 1 yr Risk of subsequent epilepsy – 2- 2.5 %

93. Diagnostic evaluation History Serum electrolytes – calcium , magnesium Blood glucose LUMBAR PUNCTURE abnormal neurological examination Ongoing seizure

94. Management During the seizure Manage as for any other acute seizure Should hospitalise Lethargy Complex features Unclear follow up

95. Long term management Primary goal – to prevent recurrences Antipyretics – to reduce fever INTERMITTENT PROPHYLAXIS Diazepam – 0.3 – 0.5 mg/ kg orally / rectally clobazem - 1mg /kg / day

96. Continuous prophylaxis Indications : Recurrent complex seizures Abnormal neurodevelopment Positive family history Sodium valproate is preferred

97. Status epilepticus A seizure that persists for a sufficient length of time / is repeated frequently enough that recovery between attacks does not occur Early status established status Epilepticus Epilepticus

98. A condition characterised by an epileptic seizure that is sufficiently prolonged or repeated at sufficiently brief intervals so as to produce an unvarying and enduring epileptic condition (dictionary of epilepsy )

99. Etiology Recurrent neonatal seizures Traumatic subarachnoid haemorrhage HIE IEM

100. Classification Generalised status epilepticus Partial status epilepticus Refractory status epilepticus Super refractory status epilepticus

101. Generalised status epilepticus Convulsive seizures Tonic clonic Tonic Clonic Myoclonic Non convulsive

102. Refractory status epilepticus Persistent seizure beyond 120 min Despite of therapy with benzodiazepine, phenytoin , phenobarbitone or valproate Treatment : Midazolam Thiopentone Magnesium Ketogenic diet

103. Intractable epilepsy It is defined as an at least one seizure every 2 months for the first 5 years of treatment & subsequently as at least one seizure per year with failure of at least 3 I st line AEDs Rx: surgery Ketogenic diet VNS

104. Misconceptions about childhood epilepsy Children with epilepsy are brain injured Has mental handicaps Only SE will harm child's brain An EEG will determine if child has epilepsy Abnormal EEG -↑ AED dose

105. Child has twitches of legs & arms while asleep. Are these seizures ? Blood level AED ↑ - change the dose ? AED – only way of treatment Surgery – after a attempting all AED Life will never be the same

106. Nursing diagnosis Risk for injury related to CNS dysfunction & inability to control self secondary to the type of seizure. Risk for aspiration & ineffective breathing pattern related to impaired motor activity, LOC. Risk for injury related to impaired consciousness & automatisms

107. Anxiety / fear related to child having life threatening seizure activity Ineffective tissue perfusion Interrupted family processes Self esteem disturbances