1. Pediatric Seizures Muhammad Waseem, MD Emergency Medicine Lincoln Hospital

2. Few things are more frightening to parents than to witness their child having a seizure

3. Objectives • Wide spectrum of Pediatric seizure • Etiologies specific to children • Treatment modalities in children • Quality of life issues • Legal implications

4. Seizure • Common neurologic disorder • 3 - 5% of children • 1/2 classified as febrile seizures • Epilepsy (0.5 - 1%)

5. Seizure • 10% ambulance calls for children • 1.5% of total ED visit • Most resolve in the pre-hospital setting

6. Seizure - ED visits • Febrile seizure 53% • Established epilepsy 31% • New-onset seizure 10% • Status epilepticus 5%

7. Causes • Idiopathic 76% • Developmental 13% • Infection 5% • Head trauma 3% • Other 2%

8. Seizure • Fit • Spell • Attack • Convulsion

9. What is Seizure?

10. Seizure • Paroxysmal, time-limited event that results from abnormal neuronal activity in the brain • Paroxysmal alteration in neurologic function (i.e, behavioral, motor, or autonomic function, or all three - volpe 1989.

11. Convulsion • A seizure with prominent motor manifestation

12. Epilepsy • Disorder of CNS whose symptoms are seizures • Recurrent seizures • Unprovoked

13. Seizure • Most seizures are not epileptic • Non-epileptic seizures are physiologic • Hypoxia • Fever • Toxins

14. Seizure • Seizure is a symptom of a disorder that need further investigations • Does not constitute a diagnosis • May occur in both normal & abnormal tissue

15. Non-epileptic Events

16. Mimic Seizures • Breath-holding spells • Syncope • Migraine • Tics • Night terror • Pseudo-seizures

17. Non-epileptic Events • Inaccurate diagnoses • Inappropriate use of AED

18. Non-epileptic Events Careful history

19. Breath-holding spells • Frightening • 6 months - 4 years • Inciting event-Shrill cry-Breath holding-Cyanosis • Disappear spontaneously before school age

20. Night Terrors • 5 - 7 years • Between midnight and 2 AM • Slow wave sleep stage 3 or 4 • Frightened and screaming • Increased autonomic activity • Sleep follows in few minutes • No recall

21. Pseudo-seizure • Diagnosis of exclusion • 10 - 18 years • Bizarre, unusual postures • Verbalization • Uncharacteristic movements • Can be persuaded to have an attack on request

22. Pseudo-seizure • Lack of cyanosis • Talking during seizure • Normal reaction to pupil • No loss of sphincter control • Normal plantar responses • Lack of post-ictal drowsiness • Poor response to AED

23. Seizure • First step in identifying the epileptic syndrome is correctly identifying the type of seizure

24. Why Should I know type of Seizure?

25. Seizure • Clue to cause • Appropriate treatment • Prognosis

26. Epileptic Seizures • Partial (40%) • Generalized • Unclassified

27. Partial Seizure • Simple Partial • Complex Partial • Partial with secondary generalization

28. Generalized • Convulsive • Non convulsive • Absence Seizure

29. Generalized- Convulsive • Myoclonic • Clonic • Tonic • Tonic-clonic • Atonic

30. Simple Partial Seizures (SPS) • Consciousness not altered • Aura • Motor activity (face, neck or extremity) • “Feeling funny” or “something crawling inside me” • No post-ictal phenomenon

31. Complex Partial Seizures (CPS) • Impairment of consciousness • Aura • Brief blank stare or sudden cessation or pause in activity • Automatism (lip smacking, chewing, swallowing and excessive salivation)

32. Complex Partial Seizures (CPS) • Dystonic posturing, tonic or clonic movement • Postictal phase • Duration 1 - 2 minutes • Usually during waking hours

33. Absence Seizure • Sudden cessation of motor activity or speech • Blank facial expression • Flickering of eye lids

34. Absence Seizure • Uncommon before age 5 year • Girls • No Aura • No postictal state • Rarely persist longer than 30 sec

35. Absence Seizure • Hyperventilation induces an absence seizure • 3/sec spike on EEG

36. Myoclonic • Quick muscle jerks • Loss of body tone • Consciousness usually unimpaired • Specific epilepsy syndromes

37. Tonic • Tonic spasms of truncal & facial muscles • Flexion of upper extremities • Extension of lower extremities

38. Clonic • Resembles myoclonus • Loss of consciousness • Slower

39. Tonic-clonic • Extremely common • Begins suddenly without warning • Tonic contraction of the trunk • Rhythmic clonic contraction alternating with relaxation of all muscle groups • Marked increase in HR and BP • incontinence

40. Tonic-clonic • Seizure last 1 to 2 minutes • Post-ictal 30 minutes to 2 hours

41. Atonic Seizures • Suddenly dropping to the floor • Lanox-Gastaut syndrome • Can occur without LOC

42. Case 1

43. Case 1 • 9-year-old boy • Parents were aroused one night by noise from his bed room • Noted bed sheets awry & breathing deeply • bitten his tongue

44. Case 1 • Confused • Afebrile

45. First Non-Febrile Seizure

46. History • Was this a true seizure or a non-epileptic event?

47. History • Circumstances • Normal activity vs. provoked • Upon awakening • Duration • Aura • Abnormal motor movements • Abnormal eye movements/automatism

48. History • Post-ictal period • Urinary or fecal incontinence • Fever, trauma or drug • Birth history • Delayed milestones • Family history of seizures

49. Physical Examination • Vital signs • Level of consciousness • Head circumference (percentile)

50. Always undress and examine the child