Seizure in children

1. SEIZURE IN CHILDREN BY Shikha.S.A 2 nd Year MSc (N)

2. Definition A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioural manifestations. Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.

3. ETIOLOGY L ow oxygen during birth H ead injuries that occur during birth or from accidents during youth or adulthood B rain tumours G enetic conditions that result in brain injury, such as tuberous sclerosis I nfections such as  meningitis   or encephalitis S troke or any other type of damage to the brain A bnormal levels of substances such as sodium or blood sugar

4. RISK FACTORS Age - The onset of epilepsy is most common during early childhood and after age 60, but the condition can occur at any age. Family history Head injuries -   Head injuries are responsible for some cases of epilepsy . Stroke and other vascular diseases -   Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy . Brain infections -  Infections such as meningitis, which causes inflammation in the brain or spinal cord, can increase the risk. Seizures in childhood -  High fevers in childhood can sometimes be associated with seizures.

5. CLASSIFICATION OF SEIZURE Seizure Generalized Partial Tonic- Clonic Absence Myoclonic Clonic Tonic Atonic Simple partial Complex partial

6. Generalized seizure Generalized Seizures (Produced by the entire brain) Symptoms 1. "Grand Mal" or Generalized tonic- clonic Unconsciousness, convulsions, muscle rigidity 2. Absence Brief loss of consciousness 3. Myoclonic Sporadic (isolated), jerking movements 4. Clonic Repetitive, jerking movements 5. Tonic Muscle stiffness, rigidity 6. Atonic Loss of muscle tone

7. Partial seizure Partial Seizures (Produced by a small area of the brain) Symptoms 1. Simple(awareness is retained) a. Simple Motor b. Simple Sensory c. Simple Psychological a. Jerking, muscle rigidity, spasms, head-turning b. Unusual sensations affecting either the vision, hearing, smell taste, or touch c. Memory or emotional disturbances 2. Complex(Impairment of awareness) Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements 3. Partial seizure with secondary generalization Symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions.

8. STATUS EPILEPTICUS (SE) I s a life-threatening neurologic disorder defined as 30 minutes or more of a continuous seizure, or two or more discrete seizures without complete recovery of consciousness between seizures. Two common forms of SE are generalized convulsive SE, involving prolonged seizures, and nonconvulsive SE, involving changes in behaviour, memory, affect, or level of consciousness.

9. Cont.……. Treatment must begin immediately after diagnosis, because SE of long duration is associated with an increase in neurologic morbidity and seizures may become less responsive to medication with time. Begin treatment with supportive care; ensuring sufficient oxygenation is essential. If seizures do not terminate on their own, administer antiepileptic medication

10. Causes of SE   Fever Pre-existing epilepsy Genetic predisposition Cerebral palsy Stroke or brain insults, such as prior or acute head trauma, CNS infection, and cerebrovascular disease including arterial ischemic stroke or intracranial haemorrhage Progressive neurologic disorders such as brain tumour or neurodegenerative disease Hypoxic-ischemic encephalopathy Metabolic and electrolyte disturbances (e.g., hypoglycaemia, hyponatremia , hypernatremia, hypercalcemia ) Drug intoxication (alcohol, cocaine, theophylline, tricyclic antidepressants, amphetamines, insulin) Acute withdrawal of AEDs Progressive neurologic disorders such as brain tumours or neurodegenerative diseases

11. IMMEDIATE CARE Verify diagnosis Obtain brief history focusing on known convulsive disorders, medication usage, and any recent medication changes, drug allergies, alcohol or substance misuse, recent acute illness, chronic disease, or previous brain injury. Initiate supportive care Assess and secure airway and oxygenation; insert nasal airway or intubate if necessary. Administer 100% oxygen Monitor pulse, blood pressure, respiration, and temperature Secure intravenous access in large vein

12. CONT….. Send blood for complete blood count, serum electrolytes, calcium, magnesium, blood urea nitrogen, liver function tests, glucose, and antiepileptic drug levels, clotting studies, and toxic drug screen Check arterial blood gases Begin isotonic saline at a low infusion rate Give 50 mL of 50% glucose intravenously if hypoglycemia is suspected, or prophylactically if glucose levels cannot be determined

13. SIGNS AND SYMPTOMS Generalized absence seizures Staring The child suddenly stops what she is doing A few seconds of unresponsiveness (usually less than 10 seconds, but it can be up to 20 seconds) that can be confused with daydreaming No response when you touch your child The child is alert immediately after the seizure The child may have many seizures per day Repetitive blinking Eyes rolling up Head bobbing

14. Generalized myoclonic seizures One or many brief jerks, which may involve the whole body or a single arm or leg In juvenile myoclonic epilepsy, these jerks often occur upon waking The child remains conscious

15. Generalized atonic seizures Sudden loss of muscle tone The child goes limp and falls straight to the ground The child remains conscious or has a brief loss of consciousness Eyelids droop, head nods Jerking The seizure usually lasts less than 15 seconds, although some may last several minutes The child quickly becomes conscious and alert again after the seizure

16. Generalized tonic- clonic seizures The child cries out or groans loudly The child loses consciousness and falls down Heart rate and blood pressure rise Sweating Tremor In the tonic phase, the child is rigid, her teeth clench, her lips may turn blue because blood is being sent to protect her internal organs, and saliva or foam may drip from her mouth; she may appear to stop breathing because her muscles, including her breathing muscles, are stiff

17. Cont......... In the clonic phase, the child resumes shallow breathing; her arms and legs jerk quickly and rhythmically; her pupils contract and dilate At the end of the clonic phase, the child relaxes and may lose control of her bowel or bladder Following the seizure, the child regains consciousness slowly and may appear drowsy, confused, anxious, or depressed.

18. Simple partial seizures Motor seizures Brief muscle contractions (twitching, jerking, or stiffening), often beginning in the face, finger, or toe on one side of the body. Twitching or jerking spreads to other parts of the body on the same side near the initial site. Other motor seizures may involve movement of the eye and head. The seizure begins the same way each time. The child remains conscious.

19. Cont …….. Sensory seizures Seeing something that is not there, such as shapes or flashing lights, or seeing something as larger or smaller than usual Hearing or smelling something that is not there Feeling of pins and needles or numbness in part of the body The child remains conscious

20. Cont …….. Autonomic seizures Changes in heart rate Changes in breathing Sweating Goose bumps Flushing or pallor The child remains conscious Strange or unpleasant sensation in the stomach, chest, or head Changes in heart rate Changes in breathing Sweating Goose bumps Flushing or pallor The child remains conscious

21. Complex partial seizures Warning sign such as a feeling of fear or nausea Loss of awareness Confusion after the seizure Loss of memory about events just before or after the seizure Loss of awareness Blank stare Walking or running Automatisms such as mouth movements, picking at air or clothing, repeating words or phrases Confusion after the seizure Loss of memory about events just before or after the seizure  

22. DIAGNOSIS Blood tests  (such as blood sugar, complete blood count, electrolytes and liver and kidney function tests) Electroencephalography (EEG) , a test that records electrical activity in the child’s brain Brain imaging tests  including  CT ,  MRI  and  PET  scans to look for any scar tissue, tumors or brain malformations that may be causing seizures Spinal tap (lumbar puncture)   to see if there is an infection or other problem PET /SPECT -Radioisotopes, radioactive materials injected into the vein and traced with either PET or SPECT with to detect areas of brain epileptic foci .  

23. TREATMENT Principles of Treatment Treatment should be started with a single conventional AED ( monotherapy ). The dose should be slowly built up until seizure control is achieved or side effects occur . If the initial treatment is ineffective or poorly tolerated then monotherapy using another AED can be tried The dose of the second drug is slowly increased until adequate or maximum tolerated dose is reached. The first drug is then tapered off slowly. Combination therapy ( polytherapy or adjunctive or “add-on “therapy) can be considered when two attempts at monotherapy with AEDs have not resulted in seizure freedom.

24. CONT…….. Phenytoin (PHT), phenobarbitone (PB), carbamazepine (CBZ), oxcarbazepine (OXC) and valproate (VPA) are usually called “conventional” or “first-line drugs”. The other AEDs are called “new "or “second-line drugs”. It is preferable to use a conventional AED as the initial drug since those are less expensive and the side effects with long-term use are well-known.

25. SURGERY Epilepsy surgery may be resective or nonresective . Resective surgery includes lesionectomy (resection of the lesion and the surrounding epileptogenic area), amygdalohippocampectomy with or without temporal lobe resection, multilobar resection and hemispherectomy . Non resective surgery includes multiple subpial transections corpus colostomy and vagus nerve stimulation (VNS)

26. Ketogenic Diet in Epilepsy H igh fat and low protein/carbohydrate diet given with/without a restricted fluid intake to maintain ketosis. I t can be used in all children above the age of 1 year with drug-resistant epilepsy. Adverse effects include GI disturbances, acidosis, increased susceptibility to infections, drowsiness, weight loss, nutritional deficiencies and rarely, renal calculi and pancreatitis. In failures it should be discontinued after in 3-6 months. In responders, it should be continued for 2-3 year.

27. IN TONIC-CLONIC SEIZURE DURING SEIZURE Remain calm Time the seizure episode If child is standing or seated, ease the child down to the floor Place pillow/ folded blanket below the child’s head. Loosen restrictive clothing Remove eye glasses Clear area of any hazards or hard object Allow seizure to end without any interference If vomiting occurs, turn the head of the child to one side. Do not attempt to restrain the child. Do not put anything in child’s mouth. Do not give any fluids or liquids.

28. After seizure Time the post ictal period Check the breathing. Check the position of head and tongue. Reposition if head is hyperextended If child is not breathing give rescue breathing and call for emergency medical service. Keep child on side Remain with child Do not give food or liquid until fully alert and swallowing reflex has returned. Check head and body for possible injury Check inside of mouth to see if tongue or lips have been bitten.

29. In complex partial seizure DURING THE SEIZURE Do not restrain Remove harmful object from area Redirect to safe area Do not agitate; instead talk in calm reassuring manner Do not expect child to follow instruction Watch to see if seizure generalize.

30. PROGNOSIS P rognosis for children with seizure depend on the etiology , type of seizure, age of onset, family and medical history. Risk factors associated with recurrence of epilepsy include: Adolescent age and older Family history of epilepsy Frequent seizure on antiepileptic medication Multiple antiepileptic therapy Abnormal EEG Seizure result from past injury/ insult .    

31. NURSING DIAGNOSIS 1. Risk for Injury related to uncontrolled seizure activity (balance disorder). 2 .Ineffective airway clearance related to blockage of the tongue, endotracheal tube, increased secretion of saliva. 3. Social isolation related to low-self against the disease state, and the bad stigma against epilepsy in the community. 4. Ineffective breathing pattern related to dyspnoea and apnoea. 5. Activity intolerance related to decreased cardiac output, tachycardia. 6. Impaired sensory perception related to disturbances in nerve sensory organs of perception. 7. Anxiety related to lack of knowledge about the disease. 8. Risk for Ineffective cerebral Tissue Perfusion related to decreased oxygen supply to the brain.