convulsions in children

Prepared by:

ANCY ANTO

M.Sc. Nursing

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’’

Patron of epilepsy.........

St.valentine

World epilepsy day

National epilepsy dayNovember 17

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

Medication does not stop all seizures .

Epilepsy is not contagious

The tongue cannot be swallowed during a

seizure

Most seizures are not medical emergencies

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

Epilepsy....

Is a disorder of the brain characterised by an

enduring predisposition to generate seizures

& by the neurological cognitive, psychological

& social consequences.

Epileptic syndrome..

Is a disorder that manifests one or more

specific types and a specific age of onset and

a specific prognosis.

Disorders mimicking seizures...

Jitteriness Benign neonatal sleep myoclonus Breath holding spells Shuddering attacks Syncopal attacks Night terror pseudo seizures

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

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

Classification of Epileptic Seizures.

Partial seizures: Simple partial (consciousness retained)

MotorSensoryAutonomicPsychic

Complex partial (consciousness impaired)Simple partial, followed by impaired consciousnessConsciousness impaired at onset

Partial seizures with secondary generalization

Generalized seizures Absences

Typical Atypical

Generalized tonic clonic Tonic Clonic Myoclonic Atonic Infantile spasms

Unclassified seizures

ILAE classificationSelf limited

Focal Generalised

Continuous

Classification of epilepsy syndromes

•Idiopathic-focal & general

•Familial

•Symptomatic

•reflex

Common causes

Infection to the central nervous system

1. Acquired bacterial meningitis

tuberculus meningitis

aseptic

encephalitis

cerebral malaria

2. Intrauterine infections

Post infectious or post vaccinal encephalopathy

Pertussis vaccination

Pan encephalitis

Post measles encephalopathy

Chickenpox encephalopathy

Disseminated encephalomyeolopathy

Metabolic causes

Dehydration

Dyselectrolytemia

Acidosis/ alkalosis

Hypocalcaemia/ hypomagnesaemia

Inborn errors of metabolism

Space occupying lesions in the brain

Neoplasm

Brain abscess

Tuberculoma

Cysticercosis

Vascular

Arterio venous malformations

Intracranial thrombosis/ haemorrhage

Coagulopathies

Congenital malformations

Migration defects

Miscellaneous

Birth trauma

Birth asphyxia

Heat stroke

Brain swelling

Poisoning

Lead encephalopathy

Breath holding spells

Gray matter degeneration

Drugs and poisons

Toxic doses of phenothiazine

Salicylate

Diphenylhydantoin

Carbon monoxide

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

Mechanisms of seizure

1. Underlying aetiology

2. Epileptogenesis

3. Excitability

4. Neuronal injury after prolonged febrile &

afebrile status epilepticus

Neuron – action potential

Basic mechanisms of epileptogenesis

Neurophysiology and neurochemistry

Epileptogenic neurons + disinhibition + circuit

PDS trigger Ca channel (Mg)

synchronization

Opens sp. K+ channel

Hyperpolarisation

Hyperpolarisation

Disappear depolarisation

seizure

Kindling

Process by which brief trans of electrical

stimuli are repeatedly delivered at

appropriate intervals to a susceptible area of

brain.

Prolonged generalised seizure

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

Excitatory & inhibitory neurotransmitters

Glutamate & aspartate – Excitatory neurotransmitters

Induces Ca + ion current

Depolarisation

seizure

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

Catecholamine's & indolamines

↓ in nor epinephrine -↑ seizure susceptibility

↑ in nor epinephrine- ↓ seizure severity

Biochemical alterations induced by seizure

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

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

Jacksonian march- Sequential progression of Clonic movements

Simple partial seizures with sensory signs.. Numbness

Tingling

Pricking

Paresthesia/ pain originating in one area

Visual sensations

Motor phenomena – posturing / hypertonia

- Uncommon < 8yrs

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

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

Patterns of motor behaviour

Stereotypic

May suddenly cease activity , appear dazed

stare into space

Confused & apathetic

Become limp or stiff

automatisms

Post ictal confusion

Exhibit oropharyngeal activities –smacking

chewing , drooling etc

Rarely exhibit – temper tantrums or rage

Generalised seizures

Tonic clonic seizures (grandmal )

- Most common

- Occur without warning

Tonic phase clonic phase post ictal phase

Tonic phase 10- 20 sec

Eyes roll upward

Immediate loss of consciousness

Stiffness

Contraction of entire body

Arms flexed

Legs, head & neck

flexed

May utter a peculiar cry

Apnoeic

Increased salivation

Loss of swallowing reflex

If standing, falls to floor or ground

Clonic phase

30 sec

Violent jerking movements

Foams at mouth

Incontinent of urine and faeces

Post ictal state

Appears relaxed

Remain semiconscious

May awake in few minutes

Confused for several hours

Poor coordination

Mild impairment in fine motor movements

Visual & speech difficulties

Vomit or complain of severe headache

Usually sleeps for several hours

Feels tired

No recollection of event

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

Manifestations:

Brief loss of consciousness

Without aura

5-10 sec

Slight loss of muscle tone

Minor movements

No incontinence

Amnesia

Need reorientation

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

Myoclonic seizures

Seizure episodes

Sudden brief contractions of a muscle

No post ictal state

May / not LOC

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

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

Jack-knife seizure – sudden dropping forward

of the head & neck with trunk flexed forward

Single momentary shock like contractions

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

Clinical features

Simple complex Absence

Clonic movements

Frequent Occasional Occasional

Post ictal impairment

Rare Frequent Never

Mental disorientation

Rare Common Unusual

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

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.

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.

Benign Occipital Epilepsy

Frequency- rare

Genetic 37%, migraine 17%

Male = female

Onset 2 - 17 years (peak:7 - 8 years)

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.

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.

Rx: VPA or ESM with control in 70 - 80%.

Evolution: Remission- 95%.

- Rare persistence of absences only- 6%.

- GTCS during adolescence or later- 40%.

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%)

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%)

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)

Poor prognosis in most cases

Tonic, atypical absence, drop attacks, other

generalized or partial seizures.

Rx: VPA,rarely with complete control.

persisting seizures.

DIAGNOSTIC EVALUATION

History collection

Physical examination

Laboratory investigations

- Serum glucose & calcium levels

• Lumbar puncture – Ist febrile seizures

protein content – increased

Imaging studies:

CT

MRI- structural lesions

PET-demonstrate perfusion,O2 & glucose intake

SPECT scan- perfusion in ictal & inter ictal state

Cerebral angiography

Magneto encephalography

Telemetry

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

Absence seizure

Abnormalities.

Slow/ abnormal rhythm-generalised ,localised

or lateralised to one side thus helps to

anatomic lesions

Spikes

Sharp waves

Poly spikes

Slow waves (hypsarrhythmia)

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

Management of child with seizures

Goals:

1. Ensure adequate vitals & oxygenation

2. Terminate seizure activity

3. Prevent seizure recurrence

4. Establish the diagnosis & treat the

underlying

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

Treatment of a newly diagnosed case of epilepsy

Newly diagnosed case

Ist monotherarpy seizure therapy

IInd monotherapy/ combination therapy seizure

free

Intractable epilepsy

Combination therapy ketogenic diet , VNS

Choice of AEDSeizure First line second line

partial CBZ, PHT, SVA , PB OXC, LTG, TPM

2nd 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

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

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

Duration – 2yrs

Sample Meals:

Meal 1:

melted butter

heavy whipping

cream

chicken

apple

sugar free Jell-O

Problems that may arise:

Low blood sugar

Lethargy

Nausea

Vomiting

Elevated cholesterol

Kidney stones

Constipation

Weight loss or gain

Dehydration

Cheating

Vagus nerve stimulation

>12 years

50% reduction in

seizures

Types of surgery

1. Resection

Removal of the area causing the seizures

2. Disconnection

Corpus callosotomy

Multiple subpial transections

3.Hemispherectomy

procedure Type

Temporal lobectomy

nonTemporal lobectomy

Corpus callostomy

Hemispherectomy

Simple/ complex partial

Partial

Partial, tonic ,clonic

Unilateral , partial , hemiparesis

Nursing management

Seizure precautions Relieving anxiety Managing treatment Providing family support & education

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

Common in 18- 22 months

Provoked seizures

Causes:

- Infections of middle ear

- URTI

- Urinary tract & GI infections

Types

Simple febrile seizures:

- 85%

- Generalised seizures

- Lasting less than 15 min

- No post ictal neurologic abnormalities

Complex febrile seizures

- Recurrent within 24 hrs

Febrile status

- A seizure with duration of 30 min

- Without regaining consciousness interictally

Risk factors

Age <18 months

Family history

Shorter duration

Recurrence

75% within 1 yr

Risk of subsequent epilepsy – 2- 2.5 %

Diagnostic evaluation

History

Serum electrolytes – calcium , magnesium

Blood glucose

LUMBAR PUNCTURE

abnormal neurological examination

Ongoing seizure

Management

During the seizure

- Manage as for any other acute seizure

- Should hospitalise

o Lethargy

o Complex features

o Unclear follow up

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

Continuous prophylaxis

Indications :

- Recurrent complex seizures

- Abnormal neurodevelopment

- Positive family history

Sodium valproate is preferred

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

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 )

Etiology

Recurrent neonatal seizures

Traumatic subarachnoid haemorrhage

HIE

IEM

Classification

Generalised status epilepticus

Partial status epilepticus

Refractory status epilepticus

Super refractory status epilepticus

Generalised status epilepticus

Convulsive seizures

1. Tonic clonic

2. Tonic

3. Clonic

4. Myoclonic

Non convulsive

Refractory status epilepticus

Persistent seizure beyond 120 min

Despite of therapy with benzodiazepine,

phenytoin, phenobarbitone or valproate

Treatment :- Midazolam - Thiopentone - Magnesium- Ketogenic diet

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 Ist line AEDs

Rx: surgery

Ketogenic diet

VNS

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

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

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

Anxiety / fear related to child having life

threatening seizure activity

Ineffective tissue perfusion

Interrupted family processes

Self esteem disturbances