20.Neonatal Convulsion
-
Upload
okto-sofyan-hasan -
Category
Documents
-
view
233 -
download
1
Transcript of 20.Neonatal Convulsion
-
8/13/2019 20.Neonatal Convulsion
1/38
NEONATAL SEIZURES
Trauma & Emergency System
Perinatologi Division.Department of Child Health
Medical Faculty of Hasanuddin University
-
8/13/2019 20.Neonatal Convulsion
2/38
Definition
Seizures are transient disturbances in brain
function manifesting as episodic impairmentsin consciousness in association with abnormal
motor or automatic activity.
-
8/13/2019 20.Neonatal Convulsion
3/38
Probable Mechanisms of Some NeonatalSeizures
PROBABLE MECHANISM DISORDER
Failure of Na + -K + pump secondary to Hypoxemia, ischemia,
adenosine triphosphate and hypoglycemiaExcess of excitatory neurotransmitter
(eg.glutamic acidexcessive excitation) Hypoxemia, ischemia
and hypoglycemia
Deficit of inhibitory neurotransmitter Pyridoxine dependency
(i.e., relative excess of excitatory
neurotransmitter)
Membrane alterationNa + Hypocalcemia and
Permeability hypomagnesemia
_________________________________________________________________
Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4thed.
-
8/13/2019 20.Neonatal Convulsion
4/38
-
8/13/2019 20.Neonatal Convulsion
5/38
Classification
I. Clinical Seizure
Subtle
Tonic
Clonic
Myoclonic
II. Electroencephalographic seizure
Epileptic
Non-epileptic
-
8/13/2019 20.Neonatal Convulsion
6/38
..Clinical Classification
1. SubttleUsually occurs in association with other types of
seizures and may manifest with:
Stereotypic movements of the extremities such as
bicycling or swimming movements.
Deviation or jerking of the eyes with repetitive
blinking
Drooling, sucking or chewing movements.
Apnea or sudden changes in respiratory patterns.
Rhythmic fluctuations in vital signs
More in preterm than in term
-
8/13/2019 20.Neonatal Convulsion
7/38
2. Tonic Primarily in Preterm
May be focal or generalized
Sustained extension of the upper and lowerlimbs (mimics decerebrate posturing)
Sustained flexion of upper with extension of
lower limbs (mimics decorticate posturing)
Signals severe ICH in preterm infants
In 85% of cases are not associated with any
autonomic changes such as increases in heart
rate or blood pressure, or skin flushing.
..Clinical Classification
-
8/13/2019 20.Neonatal Convulsion
8/38
3. Clonic
Consist of slow (1-3 /minute) rhythmic jerkingmovements of the extremities. They may be focal or
multi-focal. Each movement is composed of a rapidphase followed by a slow one.
Changing the position or holding the moving limbdoes not suppress the movements.
Commonly seen in full-term neonates >2500 grams Consciousness may be preserved
Signals focal cerebral injury, infarction or metabolicdisturbances.
..Clinical Classification
-
8/13/2019 20.Neonatal Convulsion
9/38
..Clinical Classification
4. Myoclonic
Focal, multifocal, or generalized
Focal myoclonic seizures typically involve the
flexor muscles of the extremities.Multi-focal myoclonic seizures present as
asynchronous twitching of several parts of thebody.
Generalized myoclonic seizures present asmassive flexion of the head and trunk withextension or flexion of the extremities. They areassociated with diffuse CNS pathology
-
8/13/2019 20.Neonatal Convulsion
10/38
Electroencephalographic seizure
I. Epileptic
Consistently associated with electro-cortical
seizure activity on the EEG Cannot be provoked by tactile stimulation
Cannot be suppressed by restraint of involved
limb or repositioning of the infant
Related to hyper synchronous discharges of a
critical mass of neuron
-
8/13/2019 20.Neonatal Convulsion
11/38
Electroencephalographic
seizures
II. Non-epileptic
No electro-cortical signature: seizures are
initiated in the subcortical area and are notusually associated with any EEG changes.
Provoked by stimulation
Suppressed by restraint or repositioning
Brainstem release phenomena (reflex)
-
8/13/2019 20.Neonatal Convulsion
12/38
ELECTROENCEPHALOGRAPHIC SEIZURE
CLINICAL SEIZURE COMMON UNCOMMON
Subtle +*
Clonic
Focal +Multifocal +
Tonic
Focal +
Generalized +
Myoclonic
Focal, multifocal +Generalized +
---------------------------------------------------------------------------------------------------------------
*Only specific varieties of subtle seizures are commonly associate with simultaneous
Electroencephalographic seizure activity.
Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4th
ed.
Relation between Clinical seizure and EEG seizure
-
8/13/2019 20.Neonatal Convulsion
13/38
-
8/13/2019 20.Neonatal Convulsion
14/38
Surface EEG-Silent Seizure
Can surface EEG-silent seizure in the
newborn result to brain injury?
Can this be eliminated by conventionalanticonvulsant therapy?
Further investigation needed
-
8/13/2019 20.Neonatal Convulsion
15/38
Benign Movements that are Not
Seizures
Jitteriness
Sleep apnea
Isolated sucking movements
Benign neonatal sleep myoclonus
-
8/13/2019 20.Neonatal Convulsion
16/38
Jitteriness Versus Seizure
CLINICAL FEATURE JITTERINESS SEIZURE
Abnormality of gaze or eye - +
movement
Movements exquisitely stimulus + -sensitive
Predominant movement Tremor Clonic jerking
Movements cease with passive + -
flexionAutonomic changes - +
The flexion and extension phases + -
are equal in amplitude
EEG abnormalities - +/-------------------------------------------------------------------------------------------------------------------
-
8/13/2019 20.Neonatal Convulsion
17/38
often seen in neonates with hypoglycemia, drug
withdrawal, hypocalcemia, hypothermia and in
(SGA) neonates.
spontaneously resolve within few weeks.
......Jitteriness (cont)
-
8/13/2019 20.Neonatal Convulsion
18/38
Sleep Apnea
Not associated with abnormal movements and is
usually associated with bradycardia.
When seizures are present with apnea, abnormalmovements, tachycardia and increased blood
pressure are present as well.
Isolated Sucking Movements
Random, infrequent and not well sustained
sucking movements are not seizures.
-
8/13/2019 20.Neonatal Convulsion
19/38
Benign Neonatal Sleep Myoclonus
They differ from myoclonic seizures in the
following:
can be triggered by noise or motion.
suppressed by the waking state.
not associated with any autonomic changes.
Predominantly seen in preterm neonates during
sleep. They can be focal, multi-focal, or generalized.They do not stop with restraint.
Resolve spontaneously within a few minutes and
require no medication.
-
8/13/2019 20.Neonatal Convulsion
20/38
Most Common Causes of Seizures
HIE
Infections (TORCH, meningitis, septicemia)
Hypoglycemia, hypocalcemia, hypomagnesemia
CNS bleed (intraventricular, subdural, trauma, etc.)
Less Common Causes of Seizures
Congenital brain anomalies
Inborn errors of metabolism
Maternal drug withdrawal (heroin, barbiturates,
methadone, cocaine, etc.)
Kernicterus
Pyridoxine (B6) dependency, and hyponatremia
-
8/13/2019 20.Neonatal Convulsion
21/38
Diagnosis of Seizures
Obtain a good maternal and obstetric history;
Pregnancy history is important
Search for history that supports TORCH infections
History of fetal distress, preeclampsia or maternal
infections
Delivery history:
type of delivery and antecedent events
Apgar scores offer some guidance : Low Apgar score
without the need for resuscitation and subsequent
neonatal intensive care is unlikely to be associated
with neonatal seizures
-
8/13/2019 20.Neonatal Convulsion
22/38
..Diagnosis of Seizures
Postnatal history
Neonatal seizures in infants without uneventful antenatal
history and delivery may result from postnatal cause Tremulousness may be secondary to drug withdrawal or
hypocalcemia
Temperature and blood pressure instability may suggest
infection.
-
8/13/2019 20.Neonatal Convulsion
23/38
23
Laboratory Investigations
Primary tests
Blood glucose
Blood calcium and magnesium
Complete blood count, differential leukocytic
count and platelet count
Electrolytes
Arterial blood gas
Cerebral spinal fluid analysis and cultures
Blood cultures
-
8/13/2019 20.Neonatal Convulsion
24/38
24
TORCH titers, ammonia level, head sonogramand amino acids in urine.
EEG
Normal in about 1/3 of cases
Cranial ultrasound
For hemorrhage and scarring
CT
To diagnose cerebral malformations and
hemorrhage
.Laboratory Investigations, cont
-
8/13/2019 20.Neonatal Convulsion
25/38
25
Management of Seizures
Management goals
To minimize brain damage
Achieve systemic homeostasis (airway,
breathing and circulation).
Correct the underlying cause if possible.
-
8/13/2019 20.Neonatal Convulsion
26/38
Medical Management :
10% dextrose solution (2cc/kg IV) empirically to any seizingneonate.
Anticonvulsant drugs
Calcium gluconate (200mg/kg IV), if hypocalcemia is
suspected .
Magnesium sulfate 50%, 0.2ml/kg or 2 mEq/kg.
In pyridoxine dependency give pyridoxine 50mg IV as a
therapeutic trial. Seizures will stop within minutes.
Antibiotics in suspected sepsis.
Be prepared to manage any complication
-
8/13/2019 20.Neonatal Convulsion
27/38
27
Stopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects
Phenobarbital Loading dose:10-20 mg/kg.
Add 5 mg/kg toa maximum of40 mg/kg
Maintenance:3-5 mg/kg/dayin divideddoses every 12hours.
It is the drug ofchoice.
Administer IVover 5 minutes.
Therapeuticlevel: 20-40
g/ml.
Administer IM,IV, or PO every12 hours.
Begin therapy12 hours after
loading dose.
Hypotension
Apnea
Monitorrespiratorystatus duringadministrationand assess IV
site.
-
8/13/2019 20.Neonatal Convulsion
28/38
28
Drug Dose Comments Side Effects
When seizures are not controlled with phenobarbital alone.
Phenytoin Loading dose:15-20 mg/kg IVover 30 min.
Maintenance:3-5 mg/kg/day.
Administer IV ata maximum rateof 0.5 mg/kg/min
Maintenance: 4-8 mg/kg/day byIV push or PO.
Divide total doseand administerIV every 12hours.
Do not give IM.
Toxicity is aproblem with thisdrug.
Cardiacarrhythmias
Cerebellardamage
Stopping Seizures with Anticonvulsants
-
8/13/2019 20.Neonatal Convulsion
29/38
29
rug Dose Comments Side Effects
or treatment of status epilepticus.
enzodiazepines Lorazepam:0.050.1 mg/kg
Diazepam: 0.10.3 mg/kg/dose.
Administer IV. Repeat every 15
minutes for 2-3doses if needed.
Maximum dose is2-5 mg.
It can be givenonce as a POdose of 0.1-0.3
mg/kg.
Respiratorydepression,
Interferes withbilirubin binding toalbumin
Stopping Seizures with Anticonvulsants
-
8/13/2019 20.Neonatal Convulsion
30/38
30
When to Stop Anticonvulsant Drugs /
AEDS
No specific practice guidelines for the timing forstopping these medications, however:
Stopping AEDs two weeks after last seizureepisode is acceptable as prolonged medicationcan adversely affect the developing brain.
-
8/13/2019 20.Neonatal Convulsion
31/38
31
Discontinuation before discharging from the
neonatal unit is generally recommended unless
the neonate demonstrates a significant brain
lesion on head sonogram or CT, or abnormal
neurological signs at the time of discharge.
When to Stop Anticonvulsant Drugs /
AEDS (cont)
-
8/13/2019 20.Neonatal Convulsion
32/38
Determinants of Duration of
anticonvulsant therapy for neonatal
seizures
Neonatal neurological examination
Cause of neonatal seizure
Electroencephalogram
-
8/13/2019 20.Neonatal Convulsion
33/38
Prognosis
Two most useful approaches in utilizing outcome
EEG
Recognition of the underlying neurological
disease
-
8/13/2019 20.Neonatal Convulsion
34/38
Complications
Cerebral palsy
Hydrocephalus
Epilepsy Spasticity
Feeding difficulties
-
8/13/2019 20.Neonatal Convulsion
35/38
Consultations
Neurology consult needed for
- evaluation of seizures
- evaluation of EEG and video EEGmonitoring
- management of anticonvulsant
medications
-
8/13/2019 20.Neonatal Convulsion
36/38
Further Outpatient Care
Neurology outpatient evaluation
Developmental evaluation for earlyidentification of physical or cognitive deficits
Orthopedic evaluations if with jointdeformities
Consider physical medicine/physical therapy
referral if indicated
-
8/13/2019 20.Neonatal Convulsion
37/38
References
1.Volpe JJ.Neonatal seizures. In:Neurology of the newborn.4th
ed.Philadelphia,Pa:WB Saunders's Co;2001:178-214
2.Hahn J,Olson D.Etiology of neonatal
seizures.NeoReviews.2004;5:327-3353.Riviello,J.Drug therapy for neonatal seizures:Part
I.NeoReviews.2004;5:215-220
4.Riviello,J.Drug therapy for neonatal seizures:Part
II.NeoReviews.2004;5:262-268
5.Fanaroff A,Martin R,Neonatal seizures.In:Neonatal-PerinatalMedicine-Diseases of the fetus and infant.6th
ed.St.Louis,MO:Mosby-Yearbook Inc.1997:899-911
6.Sheth R, Neonatal seizures;Emedicine.com
-
8/13/2019 20.Neonatal Convulsion
38/38
hank You