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Good Morning! Welcome Applicants!

Good Morning! Welcome Applicants!. October 21, 2011. First Nonfebrile Seizure. What to do?. Nonfebrile seizure. 25,000 to 40,000 per year Cannot be explained by an immediate, obvious provoking cause such as head trauma or intracranial infection. History. Associated factors. Age

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Good Morning! Welcome Applicants!

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  1. Good Morning! Welcome Applicants! October 21, 2011

  2. First Nonfebrile Seizure What to do?

  3. Nonfebrile seizure • 25,000 to 40,000 per year • Cannot be explained by an immediate, obvious provoking cause such as head trauma or intracranial infection

  4. History

  5. Associated factors • Age • Family History • Developmental Status • Behavior • Health at seizure onset – febrile, ill, exposed to illness, sleep deprived • Precipitating event other than illness – trauma, toxins

  6. Symptoms during seizure • Aura • Behavior • Preictal symptoms • Vocal • Motor • Head or eye turning, eye deviation, posturing, jerking, stiffening, automatisms • Respiration • Autonomic • Pupillary dilation, drooling, incontinence, vomiting • Loss of consciousness

  7. Symptoms following seizure • Amnesia • Confusion • Lethargy • Sleepiness • Headaches • Muscle aches • Transient focal weakness (Todd’s paresis) • Nausea or vomiting

  8. Is it really a seizure? • Breath-holding spells • Syncope • GERD • pseudoseizures

  9. Physical

  10. Physical Exam • State of consciousness, language, social interaction • Global development • Dysmorphic features, neurocutaneous skin findings, organomegaly, limb asymmetry • Head circumference • Neuro exam • Cranial nerves • Motor strength and tone • Reflexes • Gait • Cerebellar and sensation tests

  11. Evaluation

  12. Laboratory studies

  13. CBC, BMP, Calcium, Tox screen? • Recommendations • Should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline status • Toxicology screening should be considered across the entire pediatric age range if there is any question of drug exposure or substance abuse

  14. Exception to the rule • Children under 6 months of age • Some studies show a 70% incidence of hyponatremia associated with seizures in this age group

  15. Lumbar puncture

  16. Lumbar puncture • Recommendation • In the child with a first nonfebrile seizure, LP is of limited value and should be used primarily when there is concern about possible meningitis or encephalitis

  17. EEG

  18. EEG • Recommendation • The EEG is recommended as part of the neurodiagnostic workup of the child with an apparent first unprovoked seizure

  19. EEG • Helps to determine seizure type, epilepsy syndrome, and risk for recurrence • Optimal timing is not clear • An EEG done in the first 24 hours will most likely show abnormalities, but can be due to postictal slowing • There is no evidence that the EEG must be done before discharge from the ED • Can be arranged on an outpatient basis

  20. Neuroimaging

  21. Neuroimaging • Recommendations • If a study is obtained, MRI is the preferred modality • Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit or who has not returned to baseline within several hours after the seizure • Nonurgent neuroimaging with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neuro exam, a focal seizure, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under 1 year of age

  22. Treatment

  23. To Treat or not to Treat? • Discuss all strategies with patient/parents • Antiepileptic drugs • Special diets (ketogenic diet) • Surgery • Vagus nerve stimulation • Most neurologists do not recommend AEDs after a first seizure because only 30% have a second seizure • After 2 seizures, the risk of having a third one increases to about 75% without treatment • AED is usually started after 2 seizures • 1/3 of patients are refractory to medication

  24. Seizure Precautions

  25. Precautions • Patient/parents should be informed about possible precipitating factors: • Sleep deprivation • Hyperventilation • Alcohol abuse • Recreational drugs • Photic light stimulation

  26. Can they play sports? • Yes! They can participate in sports • Basic safety precautions • No swimming or bathing alone

  27. Can they drive? • Yes! They can drive • Each state has different laws • Most suggest being seizure free for 6-months

  28. Outer Ear Disease, Dr. Simon Noon Conference

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