The Child with Fits Lydia Burland. Learning Outcomes By the end of the session you should; Know of...

The Child with Fits

Lydia Burland

Learning Outcomes

By the end of the session you should;

Know of the common causes of seizure, including febrile fits and childhood epilepsy syndromes

Be able to explain to parents pathophysiology, as well as further investigation and management

Be able to manage seizures acutely

Be able to answer questions on the topic

Childhood Seizures

600,000 people with epilepsy in the UK

Inappropriate sensory or motor activity due to abnormal signalling in the brain

Causes include;Primary epilepsy Cranial malformationInfection Trauma/injuryFever Space occupying lesionsSyncope Electrolyte abnormality

Childhood Seizures

Focal seizures: – seizure activity in a localised part of the brain with

no loss of consciousness (LOC)– most commonly arising from the temporal and

frontal lobes

Generalised seizures: – seizure activity throughout both hemispheres,

associated with LOC– types of generalised seizure include tonic-clonic,

tonic, atonic, myoclonic and absence

Acute Management

Airway: recovery position or airway adjuncts

Breathing: O2 if needed

Circulation: get IV access and take bloods

Dysfunction: CBG, GCS and pupils

Expose: looking for causes of the seizure

Acute ManagementWith IV Access Without IV Access

0 mins Lorazepam Buccal midazolam

>10 mins Lorazepam Paraldehyde (not if unsuccessful previously)

>20 mins Phenytoin

OR (if on phenytoin)

Phenobarbital AND (if <3yrs with afebrile status) Pyridoxine

Call for senior help

Secure intraosseous access

>40 mins PICU inputConsider thiopental rapid sequence induction

PICU input

Long-term Management

If a patient presents with a seizure you should;– Take a full history– Examine fully, including CNS/PNS– If suspicious for epilepsy refer to neurology clinic– Arrange an outpatient EEG +/- imaging

Once a diagnosis is made a neurologist will decide if treatment is needed

Advice for Patients and Parents

Once a diagnosis of epilepsy has been made you should advise; Patients should not lock the bathroom door when

taking a bath

Patients should wear a helmet when riding a bike

Inform lifeguards of their diagnosis if going swimming

That epileptic patients cannot drive unless fit-free for a year

Non-Epileptic Attacks

Febrile Convulsions

Convulsion associated with high fever, in the absence of another cause

Affect 2-4% of children

Most common between 6 months and 6 years

Positive family history in around 25%

Aetiology is unclear, common precipitants include viral illness, otitis media and tonsilitis

Febrile Convulsions

Simple convulsions are;– tonic-clonic– last less than 10-15 minutes– do not recur within the same illness

Complex convulsions may start focally, last longer than 15 minutes, or recur

Febrile status occurs in 5%

Febrile Convulsions

May not need further investigation

Treat with antipyretics if the child is distressed, +/- antibiotics for the causative infection

If any doubt about the cause of the seizure a full septic screen should be performed

Treat with broad spectrum IV abx if the origin of infection is not known

Reassure parents and teach them how to manage further seizures

Reflexic Anoxic Attacks

Brief episodes of asystole triggered by pain, fear or anxiety

The child becomes suddenly pale, limp and loses consciousness, followed by a tonic-clonic phase

Episodes usually resolve in 30-60seconds, after which children may feel tired

These are non-epileptic events

Can occur at any age, but most common between 6 months and 2 years or age

Reflexic Anoxic Attacks

Diagnosis is usually based on the history, with a normal ECG and EEG

Once a diagnosis has been made parents should be reassured

If further attacks occur the child should be placed in the recovery position

The majority of children grow out of attacks, though they may recur later in life

ChildhoodEpilepsy Syndromes

Case 1

Toby is brought to see his GP as school are complaining that he is ‘day-dreaming’ in class

It happens around 10-15 times a day

He is otherwise developmentally normal

Mum says his dad use to ‘day-dream’ when he was younger

What is the most likely diagnosis?

Case 1: Childhood Absence Epilepsy

Onset between 3-12 years of age

Frequent absence episodes lasting 5-20 seconds

May have associated ‘automatisms’ such as eyelid flickering and lip-smacking

Child is otherwise normal and there is often a positive family history

Seizures remit in adolescence without treatment

The use of carbemazepine can increase seizure frequency

Case 2 A 15 year old girl is brought into A+E after she experiences a

tonic-clonic seizure

She was at a family party until late last night, where she did not drink any alcohol or use any illicit drugs

She had a similar episode after a sleep-over last month which has not been investigated

Her mum says she is clumsy and often drops things when getting breakfast ready in the morning


Case 2: Juvenile Myoclonic Epilepsy

Onset between 8-26 years, more common in girls

Characterised by;– Early morning myoclonic jerks of the upper limbs– Tonic-clonic seizures provoked by sleep deprivation– Absence seizures

May be triggered by flashing lights (40%), sleep deprivation and alcohol

The majority are well controlled with anti-epileptics, which may need to be taken lifelong

Case 3 A 9 year old presents with frequent episodes of salivation and

aphasia during the night, he is awake throughout and appears upset

His mum says she has noticed some facial twitching during these episodes

He is otherwise fit and well, and has had no day time symptoms


What would you tell his parents regarding prognosis?

Case 3: Benign Rolandic Epilepsy Onset between 3-12 years, peak at 9 years

Nocturnal, benign seizures

Unilateral paraesthesia of the face, with ipsilateral facial motor seizure

No LOC but unable to speak, and often salivation

Last around 1-2 minutes

Day time seizures are rare

Seizures resolve during puberty without treatment

Case 4 A 3 year old presents with episodes where he repeatedly

flexes his trunk forcefully and throws his arms up

His mum has also noted that he;– Is less steady on his feet– Can no longer draw or use a fork and spoon

An EEG shows asynchronous spikes on a chaotic background

What type of seizure is described?


Case 4 A 3 year old presents with episodes where he repeatedly

flexes his trunk forcefully and throws his arms up

His mum has also noted that he;– Is less steady on his feet– Can no longer draw or use a fork and spoon

An EEG shows asynchronous spikes on a chaotic background

What type of seizure is described? Infantile spasm

What is the likely diagnosis? Lennox-Gastaut Syndrome

Case 4: Lennox-Gastaut Syndrome

Triad of;– Infantile spasms– Motor regression– Typical EEG pattern

Poor prognosis with 5% mortality

Survivors have severe developmental delay and persistent seizures

Vigabatrin, steroids and ACTH can be used to control infantile spasms

EMQQuestions

Questions

a. Febrile fit b. Reflexic anoxic attackc. Absence seizure d. Benign Rolandice. Infantile spasm f. Juvenile myoclonic

1. An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

Questions

a. Febrile fit b. Reflexic anoxic attackc. Absence seizure d. Benign Rolandice. Infantile spasms f. Juvenile myoclonic

2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

Questions


3. A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

Questions

a. Tonic-clonic b. Atonicc. Absence d. Myoclonice. Focal (frontal lobe) f. Focal (temporal lobe)

4. An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

Questions


5. A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

Questions


6. A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

EMQAnswers

Answers

a. Febrile fit b. Reflexic anoxic attackc. Absence seizure d. Benign Rolandice. Infantile spasm f. Juvenile myoclonic

1. An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

Answers


2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

Answers


3. A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

Answers


4. An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

Answers

a. Tonic-clonic b. Atonicc. Absence d. Myoclonice. Focal (frontal lobe) f. Focal (temporal

lobe)

5. A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

Answers


6. A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

In Summary

Seizures in childhood are caused by many different mechanisms

The diagnosis often unclear following the 1st episode, a good history is the basis of diagnosis

Investigations include EEG and brain imaging

Prognosis is dependent upon the cause – some seizures are benign, whilst others need life-long treatment

Is it important to communicate clearly with parents and advise appropriately

Any questions?

Lydia Burland

The Child with Fits Lydia Burland. Learning Outcomes By the end of the session you should; Know of...

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