Seizure Disorder, Febrile Convulsion.pptx

Seizure disorders

1. CONVULSION / SEIZURE DISORDERS

2. Seizures (convulsions, fits) are caused by abnormal electrical discharges from the brain resulting in abnormal involuntary, paroxysmal, motor, sensory, autonomic or sensorial activity . About 5 percent children experience convulsions during the first five years of life. Motor movements consisting of tonic and clonic components are the most commonly observed phenomenon.

3. Neonatal seizures often present with twitching of the limbs, fluttering of the eyelids, sucking movements and conjugate deviation of the eyes. These should be distinguished from jitteriness, tremors, startle response to stimuli, sudden jerks on awakening and tremulousness of the hungry child.

4. Causes of convulsions Early neonatal period (0-7 days) Birth asphyxia, difficult obstructed labor Pyridoxine dependency, hypoglycemia, hypocalcemia Inborn errors of metabolism Intraventricular, intracerebral hemorrhage Neonatal period (7-30 days) Transient metabolic: Hypocalcemia,hypomagnesemia , hypoglycemia, dyselectrolytemia

5. Developmental malformations Infections: Meningitis, septicemia, tetanus neonatrum , intrauterine infections Metabolic errors: Phenylketonuria, maple syrup urine disease, galactosemia Beyond neonatal period Simple febrile convulsions Epilepsy syndromes Infections: Bacterial meningitis, intrauterine infections, tuberculous meningitis, aseptic meningitis, encephalitis, cerebral malaria, Reye syndrome

6. Metabolic causes: Dyselectrolytemia , hypocalcemia, hypomagnesemia, inborn errors of metabolism Space occupying lesions: Neoplasm, brain abscess, tuberculoma , cysticercosis Vascular: Arteriovenous malformations, intracranial thrombosis, hemorrhage Miscellaneous: Hypertensive encephalopathy, sequelae of birth trauma and birth asphyxia, gray matter degeneration Drugs, poisons: Phenothiazines , salicylates, phenytoin, carbon monoxide, lead

7. Etiology and Pathophysiology Seizures are believed to be the result of abnormal excessive concurrent electrical discharges from the cortical neuronal network of cells on the surface of the brain. Chemical changes within the neurons create an electrical negativity that enables the transfer of information between neurons.

8. When an excessive number of these cells become excited, they discharge abnormally. These cells can be triggered by either environmental or physiologic stimuli such as emotional stress, anxiety, fatigue, infection, or metabolic disturbances . An acute insult such as a CNS infection, hypoxia, and brain trauma are the most common causes in children . Some seizures are idiopathic, or not provoked by known stimuli. Genetic factors may lower the seizure threshold by making brain cells more vulnerable to abnormal electrical discharges.

9. Partial , or focal, seizures are caused by abnormal electrical activity in one hemi sphere or a specific area of the cerebral cortex, most often the temporal, frontal, or parietal lobes. The seizure may spread regionally and the symptoms are related to the region of the cortex affected.

10. In contrast, generalized seizures are the result of diffuse electrical activity that often begins in both hemispheres of the brain simultaneously and spreads throughout the cortex into the brainstem. As a result, movements and spasms displayed by the child are bilateral and symmetric. The length of a seizure, especially of a generalized seizure, is important because the airway may be compromised during the tonic phase. The basal metabolic rate rises during the peak of seizure activity, increasing the body's demand for oxygen and glucose.

11. During a seizure, the child may become pale or cyanotic as a result of hypoxia. The child may also become hypoglycemic if glucose demand is excessive.  During a seizure, the child may become pale or cyanotic as a result of hypoxia. The child may also become hypoglycemic if glucose demand is excessive .   FEBRILE CONVULSION Febrile seizures are generalized seizures that usually occur in children as the result of rapid temperature rises above 39°C (102°F) in association with an acute illness. It is the most common condition during early childhood and is defined as an event of seizure in neurologically healthy infant.

12. No evidence of intracranial infection or other defined cause is found. They are usually seen between 3 months and 5 years with a peak incidence between 17 to 24 months of age and occur in 2% to 5% of all children (2 to 5 out of 100 children ). There is often a family history of febrile seizure. In addition, children who have one febrile seizure have a 30-50% greater chance of having future seizures. Febrile seizures are most commonly reported in winter, corresponding with peaks in the occurrence of febrile illnesses in young children.

13. Types i ) Typical febrile convulsion (Benign/ simple): generalized in nature, last less than 15 minutes and do not reoccur within 24 hours of onset of fever and usually single per febrile episode. It is accounting 70-75% of febrile seizures and common between 6 months to 60 months of age and has no history of neurological infections. There may be family history of similar problem.

14. i i) Atypical / Complex febrile convulsion: Characterized by episodes that last longer than 15 minutes, may be focal in nature and multiple seizures will take place. May recurrence of convulsion within 24 hours and that has associated with postictal neurological abnormalities . Note: Recurrence after first seizure is 30-40%, of these 75% would occur within 1 year of first episodes.

15. Clinical Presentations Child experiencing a febrile convulsion may exhibit some of the following behaviors: stiff body, twitching or jerking of the extremities or face rolled eyes back, unconsciousness , confusion inability to talk problems in breathing involuntary urination or defecation vomiting sleepiness or irritability after the seizures.

16. Diagnosis History taking: History includes details of seizure, fever, perinatal history, developmental history, family history of seizure history of epilepsy. Perform a complete physical and neurologic examination: Assessing developmental milestones and correlate with age and also analyze the presentation. Lab investigation: Includes complete blood count and culture, lumber puncture, blood glucose, blood calcium, magnesium and electrolytes.

17. If the child is taking any anticonvulsants, the serum drug blood level is monitored regularly . Other advanced diagnostic test: Includes EEG (Electro-encephalogram), CT scans, MRI may be performed to identify a cerebral lesion or metabolic disorder in the brain. (Routinely not recommended).

18. Treatment The overall goal of treatment is to control seizures, reduce frequency of occurrence and identify the cause and proper treatment of that condition. So treatments include: Immediate Management (During Convulsion) Maintain airway; Place the child in semi-prone or lying the children on his/her side to prevent vomited contains from being aspirated into the lungs, clearing the airway if needed and loosening any tight clothing. Recording the start and ending time of seizure.

19. Clearing the surrounding area of unsafe items. Attending to the child for the duration of the seizures. Avoid slap or shake the child in attempt to wake during seizure. Give supportive care. Called health care professional if seizure last for longer period. Tepid sponging for fever, if not reduce give antipyretic .

20. Need hospitalization if child shows any of the following: lethargy beyond postictal state, unstable clinical features, uncertain home situations, age < 18 months, complex features and unclear follow up and child with the suspicious features of meningitis . Treatment in the hospital: If the baby is new born less than four weeks of age with fever and appear ill, give antipyretic and antibiotics until a complete work up. Maintain hydration Anticonvulsant e.g. diazepam 0.2 to 0.3 mg per kg slow intravenous route.

21. Applying tepid sponging to the face and neck. Through investigation to rule out the cause and long term management of the children. Long term management + management of recurrent attacks: Antipyretic-if temperature is high. Tepid water sponging if temperature is high, despite antipyretic therapy. Intermittent or daily prophylaxis with diazepam.

22. Intermittent prophylaxis: Administration of diazepam either rectally or orally during time of fever in a child with known history of febrile seizures. Dose 0.3 to 0.5mg per kg and repeated every 8 to 12 hours if temperature is remains 38 C or more . Daily prophylaxis: Daily use of Phenobarbital or sodium valproate for recurrent attack of febrile seizure if intermittent therapy is failed and child had positive family history of epilepsy. d. Patient education on details of disease, home care, when to seek medical attention, prognosis.

23. Nursing Management Nursing assessment: A. During a seizure, assess the followings: Difficulties with airway, breathing pattern. Type of movement observed. Time of seizure began and ended. Site where twitching or contraction began. Areas of body involved. Colour change- pallor, cyanosis, flushing. Mouth- teeth clenched, tongue bitten, abnormal movement Degree of consciousness during seizure.

24. B. After the seizure, assess the followings : Vital signs Degree of memory for recent events Type of speech Length of time the child is postictal Pupillary reaction

25. Nursing Diagnosis: Risk for injury related to seizure activity. Ineffective breathing pattern related to spasm of respiratory musculature. Social isolation related to public fears and misconception. Anxiety/ fear (Parents) related to child having seizure.

26. Nursing Interventions 1. Ensuring safety during a seizure Remove hard toys from the bed. Clear the area around the child Pad the sides of the crib of side rails of the bed. Have a suction machine available to remove secretions during a seizure. Have an emergency oxygen source in the room. Observe child closely and never leave the child alone.

27. During a seizure, monitor vital signs and assess neurological status frequently. After a seizure, check the child frequently and report the following: Behavioral change Irritability Restlessness Listlessness

28. 2. Preventing respiratory arrest and aspiration A. During a seizure, do the following actions: Do not restrain the child. Loosen the clothing especially around the neck and chest. Turn the child on side. Place a small folded blanket under the head to prevent trauma.

29. B. Suction the child and administer oxygen as indicated. C. Do not give anything by mouth or attempt to put anything in mouth. D. After the seizure place the child in side lying position . 3. Promoting socialization Advise the parents the child should be in an environment that is as normal as possible. Encourage regular attendance at school after informing the related teacher.

30. Encourage the child to participate in play or outside activities with limited restriction. Each child should be treated individually. Generally they should not be allowed to climb in high places or to swim alone. Responsible adults should be made aware of the child’s seizure disorder. Child with seizure disorder should wear a Medical Alert bracelet at all times .

31. 4. Minimizing parental fear/anxiety and increasing coping mechanism. Allow parents to remain with child during seizure. Instruct parent on proper protection, interventions during seizure: positioning, safety, airway maintenance etc. Provide information regarding nature of seizure and therapeutic intervention. Encourage family involvement in daily care of child.

32. Encourage parents to express feeling, concerns, anxiety, fears and discuss resource and support options available to family. Family Education and Health Maintenance. Reinforce realistic, reassuring information. A seizure does not necessarily imply that the underlying disease is serious. Febrile seizures are relatively common in children. Prognosis depends on the cause of the seizure. Occasional or brief seizures are thought to not have any effect on the child overall development.

33. B. Discuss and demonstrate emergency management of seizures. The child should be positioned on the side, on a flat surface to prevent fall. The surface should be padded, if possible to prevent injury. An adult should be with the child to monitor the airway and breathing until the seizure is complete. If the child vomits, immediately clear the mouth.

34. C. Stress that medical evaluation is indicated when the child develops fever. Review the technique of temperature measurement. Administration of antipyretic drugs. D . Review administration schedule, adverse effect, adverse reactions and appropriate follow up regarding anticonvulsant therapy.

35. E. Let the family know that when the child is diagnosed with febrile seizures, future events can be adequately managed at home and do not require emergency transport if less than 5 minutes in duration. Evaluation : Expected Outcome Child is free from injury Unlabored breathing after seizure with clear lungs. Parents and child verbalize the child’s ability to participate in activities. Parents participate in treatment plan.

36. Generally accepted criteria for febrile seizure A convulsion associated with an elevated temperature. A child younger than 6 years of age. No CNS infection/inflammation. No acute systemic metabolic abnormality. No history of previous afebrile seizure.