A seizure:
is a paroxysmal involuntary discharge of the brain function manifested byabnormal motor
activity, behavioral abnormalities ,sensory disturbance ,autonomic dysfunction while the
consciousness may be impaired or maintained.
Clinical approach to any new onset seizure must inquire wether really a seizure or conditions
definition:
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memic seizure and if a seizure wither provoked or unprovoked seizure.
provoked seizures: usually non epileptic triggered seizures like acute symptomatic
seizures and febrile seizures.
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-except reflex seizures which are epileptic seizures triggered by sensory stimuli.
🔻 Unprovoked seizures: are chronic seizures like epileptic seizures .
🔸 Acute Seizures: can be presented as generalized or focal convulsions.
Focal seizures could include forceful turning of the head and eyes to one side, unilateral
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clonic movements beginning in the face or extremities,while
generalized are bilateral.
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🔸Hypoxic-ischemic
According to Common Age of Presentation:
AGES 1-4 DAYS:-
encephalopathy ,Drug withdrawal, maternal drug use of narcotic
or barbiturates, Intraventricular hemorrhage ,brianmal formation, Acute metabolic
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disorders,TORCH infection, Inborn errors ofmetabolism, Pyridoxine dependency.
AGES 4th day -1st month:
- Infection Meningitis (bacterial) , tetanus , sepsis. TORCHEncephalitis,enteroviral,
Causes of Seizures ,Metabolic disorders ,Hypoglycemia, Hypocalcemia,Kernicterus, hyperbilirubinemia,
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Status Epilepticus Inherited disorders of metabolism, CNSmalformation.
is defined as continuous convulsive activity or recurrent generalized convulsive 1 mon – 6th mon :-
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seizure activity without regaining of consciousness ≥30 minutes. Infections , CNS malformation , inborn error of metabolism.
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Febrile statusepilepticus is the most common type of SE in children. 6th mon – 3 years:-
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Types of status epilepticus Febrile seizures, CNS infection , metabolic , trauma , CNSdisorders.
1- convulsive status epilepticus The most common type of SE is (generalized Elder child:-
tonic,clonic, or tonic-clonic. Epilepsy , CNS infection , trauma , CNS disorders.
2-nonconvulsive status (focal with impaired awareness, absence) manifests as
aconfusional state, dementia,hyperactivity with behavioral problems,
fluctuatingimpairment of consciousness. with at times unsteady sitting or walking..
Refractory status epilepticus is SE that has failed to respond to
therapy,usuallywith at least two medications (such as a benzodiazepine and
🔶 Acute symptomatic seizures are a provoked seizures: defined as a clinical seizures occurring
another medication)
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at the time of a systemic insult or in close temporal association with adocumented brain insult.
These seizures are caused by specific and transient pathophysiological abnormality in central
nervous system.
Etiology (mnemonic =(VITAMINS) the interval between occurrence of seizure varies according to etiology. seizure events can
1- Vascular ischemic (arterial or venous) stroke; intracranial hemorrhage happened within 1 week of acute brain insult in cases of stroke, traumatic brain injury, anoxic
2- Infection encephalitis; meningitis encephalopathy, or intracranial surgery; at first identification of subdural hematoma; at the
3- Traumatic acute head trauma presence of an active central nervous system (CNS) infection; or during an active phase of multiple
4- Autoimmune autoimmune encephalitis
5- Metabolic hypoglycemia hypocalcemia; hyponatremia; hypomagnesemia.
Malformations of brain
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sclerosis or other autoimmun diseases.In addition,
a diagnosis of acute symptomatic seizure should be made in the presence of severe metabolic
derangements (documented within 24 h by specificbiochemical or hematologic abnormalities), drug
6- Inborn errors of metabolism: such as nonketotic hyperglycinemia in neonates and
mitochondrial encephalopathy with lactic acidosis folinic acid and pyridoxine and 🔸
intoxication or and withdrawal,or exposure to well-defined epileptogenic drugs. ;
the prognosis depends on the underlying disorder, including its reversibility or treatability and the
pyridoxal-phosphate dependency (these usually presentin infancy, but childhood onset is
also possible)
7- Intoxication (e.g.,tricyclic antidepressants) drug withdrawal or overdose in patients
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likelihood of developing epilepsy from it.
Acute symptomatic seizures caused by (mnemonic =(VITAMIN)
V= vascular – cerebrovascular accident (CVA)
taking AEDs I= infection inside the CNS as meningoencephalitis
8- Neoplastic ( brain tumors) Status Epilepticus T= traumatic head injury
9- Systemic conditions (such as hypertensive encephalopathy,, renal or hepatic A= autoimmune
encephalopathy M= metabolic increase (sugar Ca Mg Na) or decrease Na
I= intoxication , inborn error of metabolism
N = neoplastic
Treatment of status epilepticus
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Interventions for emergency department, in-patient setting, or prehospitalsetting.
A- 0 - 5 minutes stabilization phase:-
1. Stabilize patient (airway, breathing, circulation, disability-neurologicexam)
🔶 Febrile Seizures ( are provoked seizures)
The international league against epilepsy define febrile seizure as seizures occurring in childhood after one month to 5 years of age
2. Time seizure from its onset, monitor vital signs associated with:-
3. Assess oxygenation, give oxygen via nasal cannula/mask, considerintubation if respiratory assistance needed. a- febrile illness not caused by an infection of central nervous system
4. Initiate ECG monitoring b- no previous neonatal seizure or previous unprovoked seizures or other acute symptomatic seizure.
5. Collect finger stick blood glucose. If glucose <60 mg/dl then Children ≥ 2 years: 2 mL/kg D25W IV .Children < 2 American Academy of Pediatrics (APP) define Febrile seizures as seizures that occur:
years: 4mL/kg D12.5W between the age of 6 and 60 months with a temperature of 38C or higher,that are not the result of central nervous system infection or
6. Attempt IV access and collect electrolytes, hematology,toxicology screen, (if appropriate) anticonvulsant drug any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures.
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levels.Does seizure continue? If yes start initial therapy phase.
B- 5 - 20 minutes initial therapy phase:-
A benzodiazepine is the initial therapy of choice Choose one of the following 3 equivalent first-line options with
it is the most common cause of convulsions in children and occurs in 2 - 5 % of all children between 6 months to 5 years of age. factors
like male predominance ,genetic factors, younger age as well as family history of FS are some of the notablefactors having association
with FS, Autosomal dominant inheritance pattern isdemonstrated in some families .
dosing andfrequency: Types:
1- Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13−40 kg, single dose. 1- simple febrile seizure
2- Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat doseonce.
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3- Intravenous diazepam (0.15−0.2 mg/kg/dose, max 10 mg/dose, may repeatdose once.
If none of the 3 options above are available, choose one of the following:
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2- complex or atypical febrile seizure
simple febrile seizure criteria:-
1- Fever (temperature of 38c or mor)
1-Intravenous phenobarbital (15 mg/kg/dose, single dose, 2- Generalized tonic-clonic seizure3- Duration few seconds to less than 15 minutes
2- Rectal diazepam (0.2−0.5 mg/kg, max: 20 mg/dose, single dose, 4- Usually not recur same day
3- Intranasal midazolam , buccal midazolamIf patient improves and return to baseline, then symptomatic medical 5- No focal neurological signs6- Focus of infection is present like URI7- No signs of increased intracranial pressure
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care.Ifpatient not improved then start Phase 2
C- Phase 2 :-
20 - 40 minutes Choose one of the following second-line options and give as a single dose Intravenous fosphenytoin
8- Normal CSF findings and normal interictal EEG
9- Normal neurodevelopment of the child
Most patients with simple febrile seizures have a very short postictal state and usually return to their baseline normal
(20 mg PE/kg, max: 1500 mg PE/dose, single dose, OR Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, behavior and consciousness within minutes of the seizure.
single dose, OR Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single dose, If none of the options above
are available, choose one of the following (if not givenalready) Intravenous phenobarbital (15 mg/kg, max dose, )If 🔶 Complex or atypical febrile seizure criteria:
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patient improved, then symptomatic medical careIf not improved continue 3rd therapy phase
D- 40- 60 minutes 3rd therapy phase Choices include: repeat second-line therapyor anesthetic doses of either
thiopental, midazolam, pentobarbital, or propofol (all with continuous EEG monitoring).
-Complex febrile seizures were defined as focal, prolonged (15minutes ormore)
-and/or recurrent within 24 hours or both
-has long period of postictal drowsiness.
If patient improved then symptomatic medicalcare -It may be accompanied by transient hemiparesis or Todd’s paralysis
-and may present in children with neuro-developmental problems.
-The most severe type of complex febrile seizure is known as febrile status epilepticus which means that febrile seizure occurs either
as continuous or intermittent without recovering consciousness for more than 30 minutes .
-it accounts for 25–52% of all cases of status epilepticus in children .
Etiologies of neonatal seizures: -Patients with febrile status epilepticus have a high chance to develop hippocampal lesions in the future.
🔹 1- Hypoxic-ischemic encephalopathy.
This is the most common cause of neonatalseizures, accounting for over 50% of cases. HIE can be global, as in perinatalasphyxia or
🔸 Risk factors for recurrence of febrile seizures
-Febrile seizures recur in approximately 30% of those experiencing a first episode, in50% after two or more episodes, and in 50% of
focal (i.e., arterial infarction). In perinatal asphyxia, the seizures occur
in the context of a newborn who has a history of difficulty during labor and delivery,often seen within the first 12 to 24 hours .seizures
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infants younger than 1 yr of age atfebrile seizure onset.
Major risk factors:
•Age < 1 year
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are usually focal and may bemultifocal.
2. Intracranial hemorrhages (ICHs)
are responsible for 10% to 15% of neonatalseizuresa- In the term infant, primary subarachnoid hemorrhage (not due to extensionof a Seizures are possibly the most important and common indicator of significant neurologic dysfunction in the neonatal period.
•Duration of Fever <24 hr
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•Fever 38 - 39 c.
Minor risk factors:
deeper cerebral or intraventricular hemorrhage).seizures, usually on thesecond day of life.B-Subdural hemorrhages are related to large 🔷 Types of Neonatal Seizures: Acute Seizures in
•Family history of febrile seizure
•Family history of epilepsy
infant size, breech delivery, andinstrumentation.Presenting seizures are usually focal and occur in the first fewdays of life. c- In the
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There are two main neonatal seizure types: electroclinical seizure and electrographic seizure only.
children
Acute symptomatic seizures •Complex febrile seizure
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preterm infant, germinal matrix, intraventricular and parenchymalhemorrhages .Seizures typically occur after the first 3 days of life. 1- Electroclinical seizures associated with EEG changes can be categorized as •Day care
a- Motor seizures include automatisms, clonic seizures, epileptic spasms, myoclonic seizures, and tonic seizures. •Male gender
3-CNS infections account for about 5% of neonatal seizures. b- Non-motor seizures include autonomic seizures and behavioral arrestc- Sequential type for “events with a sequent of signs, symptoms, and EEG changes at •lower serum sodium at time of presentation
a- Congenital intrauterine infections, such as with cytomegalovirus (CMV),toxoplasma,rubella and herpes viruses may present early different times.” An example would be a sequence of tonic, then clonic, then automatisms, and autonomic manifestations with varying lateralization during one Having one risk factor, 25–50%; two risk factors, 50–59%; three or more risk factors, 73–100%.
(first 2 days) withseizures in severe cases.The clinical scenario may include microcephaly, poorintrauterine growth, prematurity, and other
skin, ophthalmic, and systemicfindings. 🔹
seizure.
2- Electrographic only. :
- seizures that appears only by EEG and no clinical seizure often seen in premature infants and Hypoxic-ischemic encephalopathy.
RISK FACTORS FOR OCCURRENCE OF SUBSEQUENT EPILEPSY
b- Postnatal sepsis, for example, with group B Streptococcus or Escherichia coli,isoften complicated by meningitis and may be Diferentiating seizure types based on clinical appearance alone is challenging. Thus in many cases, specifcally in sick neonates with a history of suspected
associated with seizures. In thissetting, the newborn has often been well for a couple of days, only to deterioratelater with seizures neurologic injury, continuous bedside EEG is necessary to make this distinction.Motor electroclinical Seizures
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occurring after the first 48 to 72 hours. 1- Automatisms
Automatisms include transient eye deviations, nystagmus, blinking, mouthing, and abnormal extremity movements (rowing, swimming, bicycling, pedaling, and
4. Acute Metabolic Disorders. These rapidly remediable conditions are the focus ofthe initial investigations in neonatal seizures and stepping). Automatisms occur more commonly in premature than in full-term infants.
include hypoglycemia,hypocalcemia, hypomagnesemia, and hyponatremia. They account for 5% ofneonatal seizures. 2- Clonic seizures (Focal or multifocal) :-
a-Hypoglycemia :- definition of hypoglycemia is controversial, but reasonablethresholds for treatment are ˂40mg/dL (˂2.2 mmol/L) in Rhythimic movements of muscles groups They have both fast and slow components Occur with frequency of 1-3 jerks /sec. Commonly associated with EEG changes
the first 24 hours, and ˂50mg/dL (˂2.8 mmol/L) after 24 hours. Causes of neonatal hypoglycemia include .3- Tonic Seizures (focal or generalized ):-
Sustained flexion or extension of truncal or limb muscles (decerberated or decorticated posturing) ,Usually no EEG changes on generalized tonic seizures
decreased glucose supply, as in the premature and small-for-gestational-ageinfant, as well as disorders in which pathways of 4- Myoclonic Seizures (Focal, multifocal, and generalized types)
gluconeogenesis are deficient or suppressed Such as inborn errors of metabolism and increased utilization, such asin hyperinsulinemic Random, single, rapid contractions of muscle groups of the limbs, face, or trunk Typically not repetitive or may recur at a slow rate May be generalized, focal, or
states, most commonly seen in the infant of the diabeticmother. fragmentary May be provoked by stimulationPresumed pathophysiology: may be epileptic or nonepileptic and Predilection for flexor muscle groups, and Carry the
b-Hypocalcemia. Whole blood ionized calcium (iCa) is the best measure of calciumstatus in ill infants. Hypocalcemia is considered worst prognosis. Clinical Evaluation
5- Epileptic Spasms A detailed history should be extracted to identify whether the convulsion is febrileor afebrile; to find out the degree of fever
present when ionized Ca in terminfants or prematures ˃1,500 g birth weight is ˂4.4 mg/dL (˂1.1 mmol/L) and inpremature infants ˂1,500 g Epileptic spasms are sudden generalized jerks lasting 1-2 seconds that are distinguished from generalized tonic spells by their shorter dura- tion and by the fact that and its relationship to convulsion,duration of convulsion, type of seizure, the extent of postictal drowsiness, andvarious
at birth, ˂4.0 mg/dL (˂1 mmol/L). Most cases areasymptomatic. Symptoms of hypocalcemia include jitteriness, stimulus-inducedmuscle spasms are usually associated with a single, very brief, generalized discharge. associated systemic symptoms . Differential Diagnosis of fever and convulsion include:-
jerks, seizures, and rarely laryngospasm.Early-onset hypocalcemia occurs in the first 3 days of life and is associated withprematurity, Nonmotor electroclinical Seizures •Other relevant history includes history ofseizure, recent vaccination, attending daycare center, or prior treatment 1- Febrile seizure ( simple or complex)
1- Autonomic seizures withantibiotics or any drugs during this episode and any other symptoms related tomeningitis or encephalitis.
infants of diabetic mothers, intrauterine growth retardation, andperinatal asphyxia. Late-onset hypocalcemia can occur because of 2- CNS infection (meningitis, encephalitis)
hypoparathyroidism, the feeding ofhigh-phosphate formula , hypomagnesemia.
c-Hypomagnesemia. The most common cause is transient neonatalhypomagnesemia. It causes parathyroid hormone resistance and, so,
typically accompany additional seizure types and are rarely seen in isolation.involve fuctuations in autonomic system func- tion, including alterations in the
cardiovascular, vasomotor, pupil- lary, and thermoregulatory function. Teseseizures may include heart rate changes, hypertension episodes, and apnea.
2- Behavioral Arrest
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•Past history and family history of febrile or afebrileseizures, detailed birth and development history are also important.
Febrile seizures ofen occur in the context of otitis media; roseola and human herpes virus (HHV) 6 infections; and infections
with norovirus, parecho virus,enteroviruses, Shigella, or similar agents, making the evaluation more demanding.In patients with
3- Fever triggering in children with epilepsy
4- Other precipitants of seizure in children with fever
(electrolytes imbalance ,hypoglycemia, head trauma ,
causeshypocalcemia. Hypomagnesemia must be corrected before the hypocalcemia canbe corrected .Levels ˂1.4 mg/dL (˂0.6 mmol/L) Behavioral arrest seizures include cessation of activity or immobiliza- tion. Tis seizure type is rarely seen in isolation and can be seen as a component of sequential
seizures.Seizures Versus Jitteriness:- Jitteriness or tremors in neonates differ from seizures by the following characteristics:- 🔸
febrile status epilepticus, HHV-6B (more frequently) and HHV-7infections may account for 30% of the cases.
The child should be monitored at the time of admission.
intoxication)
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are considered low.
5-Malformations/structural lesions.
5% of neonatal seizures are caused bycerebral dysgenesis.Cerebral dysgenesis can cause seizures from the first day of life. This is most
● Fast movements ( 4- 6/sec)
● Provocated by stimulation
A thorough general and neurological examination includes cranial nerves, motor systems, and fundal examination needs to be
completed to identify the cause of fever and to exclude possible differential diagnoses such as meningitis (bulging fontanelle,
neck stiffnessor kerning sign and Brudzinski’s sign) and encephalitis.
● Ended by holding or flexion of the limbs
likelywith the more severe disorders, such hemimegalencephaly, , and polymicrogyriaslissencephaly. (Seizures are often very refractory ● No abnormal eye movemens
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to medications.)
6. Inborn errors of metabolism. (IEM):-
Typically caused by an enzyme defect inthe metabolic pathways of carbohydrates, proteins, or fat, In these disorders,infants initially
Investigations:-
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🔸 Lumbar Puncture:
1- differentiating febrile seizures from serious infection like bacterial meningitis isessential but remains clinical dilemma
for many clinicians in the emergencysetting. children between the ages of 6 and 18 months are especiallyproblematic as
appear well due to the benefits of placental clearance of toxins untilbirth and only become encephalopathic and have seizures after 2 specific localizing signs and symptoms of meningitis may notmanifest or be minimal so some clinician advocating routine
to 3 days.Biochemical markers for these disorders include hypoglycemia,metabolic acidosis,hyperammonemia,and there is family history
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lumber puncture inall infants less than 18 months of age with first febrile seizure irrespective ofclinical findings.
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of similar illness or death. 2- Due to the low risk of meningitis in children with first simple febrile convulsionin areas with good immunization
coverage American Academy of pediatrics recommends the following indications:-
7- Pyridoxine dependency, although rare, is an important cause of neonatalseizures as treatment is available. A-should be performed for:
A test dose of pyridoxine 100 mg IV, with EEG,and cardiorespiratory monitoring, resulting in immediate seizure cessationand resolution of 1- all infants younger than 6 mo of age who present with fever and seizure. Treatment
EEG abnormalities within hours, is diagnostic. 2- at any age if there are clinical signs or symptoms of concern. For parents and caregivers, witnessing a seizure can be a distressing experience,signifcantly impacting their quality of
3- febrile status epilepticus . life.The important steps in treatment of febrile seizures are:-
DIAGNOSIS: 4- complex febrile seizure in patients with a suspected CNS infection. 1- Manage acute febrile seizure and acute illness.
simply taking the prenatal and postnatal history and performing an adequatephysical examination .Careful neurologic examination of the infant might uncoverthe B- in a infants between 6 and 12 months of age LP should be strongly considered if:- 2- Determine risk factors for recurrence and estimate risk of recurrence of thefebrile seizures.
cause of the seizure disorder . 1- not immunized against Haemophilus influenza type b and Streptococcus pneumonia. 3- Determine risk factors for later epilepsy.
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Examination of the retina might show thepresence of chorioretinitis, suggesting a congenital TORCH infection. 2- the immunization status is unknown. 4- Counsel parents about risk of recurrence and how to provide first aid andmanage fever.
An unusualbody or urine odor suggests an inborn error of metabolism. 3-children have been pretreated withantibiotics.( mask the signs and symptoms of meningitis) A- Treatment of an acute episode:-
Investigations The approach to investigations should be individualized with an emphasis onearly identification of correctable disorders and directed according to the Neonatal Seizures C- child between 12 and 18 months should also be considered for lumbar punctureas there are usually slight symptoms
of meningitis clinically. 🔸
In most cases, simple febrile seizure spontaneously ceases within 2-3 min, and does not require treatment.
🔸 Search for cause of fever.
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clinical findings.
🔹 1- Blood:- should be obtained for determinations of glucose, calcium, magnesium,electrolytes, and blood urea nitrogen ,bilirubin ,blood culture, urine culture. D- children above 18 months, a lumbar puncture is needed in the presence ofclinical signs and symptoms of
meningitis (such as neck stiffness, Kernig andBrudzinski signs) or if the case suggests intracranial infection . 🔸 Antipyretics:
decrease the discomfort and not reduce the risk of having arecurrent febrile seizure. ( seizure often occurs as the
🔹 2-lumbar puncture:- indicated in neonates with seizures due to sepsis ,neonatalmeningitis , intracranial hemorrhage, some inborn errors of metabolism.
3- General metabolic screening:- screening for inborn errors of metabolismincluding serum ammonia ,arterial blood gase for acidosis and other
🔶 .🔸 ( ACETAMINOPHEN 10–15 mg/kg/dose PO/PR Q4–6 hr; max. dose: 90mg/kg 24 hr OR IBUPROFEN 5–10
temperature is rising or falling)
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investigationsshould all be considered and the approach modified by the individual case history.
4-NeuroimagingCranial ultrasound examination can be accomplished at the bedside and may identifyintracranial hemorrhage, especially in the premature.Head
Electroencephalogram
not need to be performed as part of the evaluation If the child is presenting withthe first simple febrile seizure and is otherwise
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mg/kg/doseQ6–8 hr PO; max. dose: 40mg/kg/24 hr PO)
Educated parents about the features of febrile seizures and how to handle aseizure acutely, and about the risk of
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CT, and especially brain MRI are more helpful in Infants with focal seizure andstructural abnormalities, intracranial hemorrhage.
5- EEG
neurologically healthy because:-
1- not predict the future recurrence of febrile seizures or epilepsy even if the resultis abnormal. recurrency and subsequentepilepsy(see the tables).
a-can show epileptiform activity (e.g., sharp waves) between the seizures (suggestingan increased risk for seizures) and confirm electrographic seizure activity if a
clinicalseizure is recorded. 🔻
2- Often nonspecific if performed within 2 wk of a febrile seizure.
indicated in the following conditions:- 🔸
❖ If the seizure lasts for longer than 5 min.
Rectal diazepam 0.2mg – 0.5 mg/ kg ( maximum 10 mg) or buccalmidazolam (0.3 mg/kg, max 10mg) can be used at
b-EEG monitoring is often necessary because electrographic seizures can occurwithout observed clinical signs (electroclinical dissociation). a- if the risk of epilepsy is highly suspected (see the table of the risk of epilepsy)
b- if patient does not recover immediately from seizure to distinguishedbetween ongoing seizure activity and postictal 🔸Instruct on the appropriateness of anticonvulsive therapy, whenprescribed, including the relevant side effects.
home as rescuemedication.
TREATMENT OF NEONATAL SEIZURES
state (postictal state ofsimple febrile seizure usually minutes
c- febrile status epilepticus.
🔶B- Prevention seizures with risk of recurrence:-
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🔸 A- treatment of common acute metabolic derangements.
1-hypoglycemiaa-initial treatment 200 mg/kg of glucose over 1 minute, to be followed bycontinuing therapy .This initial treatment is equivalent to 2 mL/kg of dextrose 10%water (10% D/W) 🔶 Blood Studies
❖ prophylactic antiepileptic therapy is not recommended for simple febrileseizures due to the benign prognosis and
the risk of side effect of this drugs.
❖ If there is history of frequently recurring short febrile seizures(3 or more in6mo or 4 or more in year). or in patients
infused intravenously.b- Continuing therapyInfusion of glucose at a rate of 6 to 8 mg of glucose/kg /minute. ( 10% D/W at a rate of 86.4 mL/kg per day or 3.6 mL/kg per hour gives 6 mg/kg per 1- Simple febrile seizure. Serum electrolytes, calcium, phosphorus, magnesium, complete blood count not routinely with febrile status epilepticus orrecurrent complex febrile seizure, Give intermittent prophylaxis during thefebrile
minute of glucose.) recommended: the decision on whether or not to perform the tests should exclusively aim at identifying the cause of fever illnesses(2-3days):-- intermittent oral clonazepam (0.01 mg/kg every 8-12 hr up to amaximum dose of 1.5 mg/day)- or
Recheck glucose level 20 to 30 minutes after IV bolus, and then hourly until stable,to determine if additional therapy is needed. Additional bolus infusions of 2 mL/kgof 10% D/W may be needed. (search for fever etiology ) oral (0.3 mg/kg) or rectal (0.5 mg/kg) diazepam 8 hourly can begiven
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If glucose is stable and in acceptable range, feedings may be continued and theglucose infusion tapered as permitted by glucose measurements prior to feeding.
2-Hypocalcemia Emergency calcium therapy (for active seizures ) consists of 100 to 200 mg/kg of10% calcium gluconate (9–18 mg of elemental calcium/kg) by intravenous infusionover 10
to 15 minutes.Monitor heart rate and rhythm and the infusion sitethroughout the infusion.
● Blood glucose is needed to measured initially or subsequently if there isprolonged postictal obtundation or poor oral intak.
● serum electrolyte are needed if clinically indicated (eg dehydration).( lowserum Na associated with a higher risk of
recurrence of the febrile seizurewithin the following 24 hr.)
Repeat the dose in 10 minutes if there is no clinicalresponse. Following the initial dose(s), maintenance calcium should be giventhrough continuous intravenous infusion. 200–800 mg/kg/24 hr ÷ 2-Complex febrile seizure Performance of blood chemical tests: decision is related to clinical condition.
Q6 hr .IVinfusion: Do not exceed 120–240 mg/kg/hr with a max. concentration of 50mg/mL. Therapy with calcium is usually adequate for most cases. In some casesconcurrent therapy with
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magnesium is indicated.
Before you start calcium parenteral therapy the following precautions must beconsidered:-
🔶 CT or MRI (Indicated in febrile status epilepticus)
a-Rapid intravenous infusion of calcium can cause a sudden elevation of serumcalcium level, leading to bradycardia or other dysrhythmias. ❖ is not recommended after first simple febrile seizure.
b- Infusion by means of the umbilical vein may result in hepatic necrosis if thecatheter is lodged in a branch of the portal vein. ❖ needs to be individualized in complex febrile seizures (eg.if the childneurologically abnormal)
c. Rapid infusion by means of the umbilical artery can cause arterial spasms and, atleast experimentally, intestinal necrosis and thus, is generally not indicated.d. Intravenous calcium
solutions are incompatible with sodium bicarbonate sincecalcium carbonate will precipitate.
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e. Extravasation of calcium solutions into subcutaneous tissues can cause severenecrosis and subcutaneous calcifications.
3- hypomagnesemia Hypocalcemia seizures with concurrent hypomagnesemia should include treatment for the hypomagnesemia. The preferred preparation for treatment
ismagnesium sulfate. 🔶 Breath-Holding Spells
The 50% solution contains 500 mg or 4 mEq/mL. Correctsevere hypomagnesemia (˂1.6 mg/dL) with 50 to 100 mg/kg of magnesium sulfate intravenously given over 1 to 2 hours.
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When administering intravenously, infuseslowly and monitor heart rate. The dose may be repeated after 12 hours. Obtainserum magnesium levels before each dose. 🔸
usually begin between 6 and 18 months of age. Due to immaturity of theautonomic system and occur in two diferent forms.
1- pallid breath-holding spell,:-
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B- treatment of other underlying causes (eg . sepsis, IEM, electrolyte imbalance).
Anticonvulsant medication 🔸
a silent cry with marked pallor caused byvasovagal reflex lead to refex vagal-cardiac bradycardia and asystole.
2- the cyanotic or, “blue,” breath-holding spell:-
Episodes usually start with a cryleading to prolonged expiratory apnea and intrapulmonary shunting isresponsible for the cyanotic
When anticonvulsant treatment is indicated, phenobarbital is the drug mostcommonly used as first-line therapy. Other first-line options includebenzodiazepines (diazepam, lorazepam) and
phenytoin or, if available, its prodrugfosphenytoin. episodes.
i. Phenobarbital is the initial drug of choice. Education and reassurance of the parents is usually all that is needed, as theseepisodes are, as a rule, self-limited and outgrown
It is given as a loading dose of 20mg/kg IV. If seizures continue, additional loading doses of 5 to 10 mg/kg IV maybe given as needed to control seizures until a cumulative dose of 40 mg/kg is within a few years. However,treatment of coexisting iron deficiency is needed if it is present. Education of the parents on how to
handle more severe spells by first-aid measures is important
reached.
A maintenance dose of 3 to 5 mg/kg/day PO or IV divided bid shouldbe started 12 to 24 hours after the loading dose. During loading doses of phenobarbital, the newborn needs to be
monitored closely for respiratory depression.
🔶 Syncope
Syncope can present with drop attacks triggered by a sudden cutting off of oxygento the brain, lead to generalized convulsions,
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The use of phenobarbital can be associated with electroclinical dissociation,where electrographic seizures persist despite the resolution of clinical seizures,after the drug is give Subsequent termed anoxic seizures.
EEG monitoring is therefore imperative to rule out subclinical seizure activity. 1- Vagal syncope.
ii. Phenytoin The loading dose is 15 to 20 mg/kg IV over 20 minutes diluted innormal saline 1 mg /1ml (don,t dilute in dextrose) administered at no greaterthan 1 mg/kg/minute (toavoid A- Vasovagal (neurocardiogenic) syncope most common mimickers of generalized tonic clonic seizures and is usuallytriggered
cardiac arrhythmia and hypotension)followed by a maintenance dose of 4to 8 mg/kg/day divided q8h. Fosphenytoin It is highly soluble in water and canbe administered very safely intravenously by dehydration, heat, standing for a long time without movement, hotshowers, the sight of blood, pain, or sudden stress. History is
and intramuscularly, without causinginjury to tissues. Fosphenytoin is administered in phenytoin equivalents (PE). Conditions That usually the clue todistinguishing syncope from epileptic seizures. There is initially pallor and sweatingfollowed by blurring of
The usual loading dose of fosphenytoin is 15-20 PE/kg administered over 30min. Maintenance doses of 4-8 PE/kg/day can be given. vision, dizziness, nausea, and then gradual collapse withloss of consciousness
iii. Benzodiazepines Diazepam, lorazepam, and midazolam Clonazpam. Onset ofaction is within minutes however, duration of action is longer for lorazepam (upto 24 hours). Lorazepam is Mimic Seizures B- Vagovagal syncope is triggered by swallowing or vomiting, Sudden coldexposure to the face or to the body and can progress
🔸
often used in the acute treatment of neonatal seizures; it is distributed to the brain very quickly and exerts its anticonvulsanteffect in less than 5 min. It is not very lipophilic and does not clear to convulsive seizure ifthe asystole is sufficiently prolonged.
out from thebrain very rapidly. Its action can last 6-24 hr. Usually, it does not causehy potension or respiratory depression. 2- Cardiac Syncope Long QT syndromes (LQT) can cause life-threatening “pallid” or white syncope.Accompanying this are
The dose is 0.1 mg/kg when used foracute treatment of seizures, and 0.05 mg/kg (range: 0.02-0.10 mg/kg) every 4-8 ventricular arrhythmias,
hr when used as scheduled medication a Diazepam may be more effective as acontinuous infusion. Diazepam dose is 0.3 mg/kg IV. All family members of an affected LQT syndrome individual should be investigated.
Midazolam doses used have been in the range of 0.05-0.15 mg/kg as an initial intravenous bolus, with acontinuous infusion of 0.5-1 μg/kg/min intravenously that can then be gradually titrated Affected individuals need insertion of cardiac defibrillators, and their familiesshould be taught CPR. As a rule children with new
upward, if tolerated, every 5 min or longer, to a maximum approximately 33 μg/kg/min (2 mg/kg/hr).if you used high dose infusion it needintubation and mechanical ventilation. Clonazpam 0.1- onset seizure disorder should getan electrocardiogram (ECG) to rule out LQT syndrome masquerading as seizuredisorder.
0.2 mg/kg iv bolusfollowed by iv infusion of 10- 30 microgram/kg/hr. Cardiac syncope is usually sudden without the gradual onset and the symptomsthat accompany vagal syncope. Aortic stenosis
can cause sudden syncope at theheight of the exercise (usually hypertrophic), or directly at the end (usuallyvalvular) and, if
🔶
suspected, warrants an echocardiogram.
Other conditions mimic seizure
1) Normal physiologic phenomenon Sleep myoclonus
2) Exaggerated physiologic reaction Startle
3) Benign paroxysmal vertigo
4) Behavioral :- Day dreamNight terrorsShuddering
5) Psychatric :-Pseudoseizure and Panic attack
by fatema okoff
is a paroxysmal involuntary discharge of the brain function manifested byabnormal motor
activity, behavioral abnormalities ,sensory disturbance ,autonomic dysfunction while the
consciousness may be impaired or maintained.
Clinical approach to any new onset seizure must inquire wether really a seizure or conditions
definition:
🔸
memic seizure and if a seizure wither provoked or unprovoked seizure.
provoked seizures: usually non epileptic triggered seizures like acute symptomatic
seizures and febrile seizures.
🔸
-except reflex seizures which are epileptic seizures triggered by sensory stimuli.
🔻 Unprovoked seizures: are chronic seizures like epileptic seizures .
🔸 Acute Seizures: can be presented as generalized or focal convulsions.
Focal seizures could include forceful turning of the head and eyes to one side, unilateral
🔸
clonic movements beginning in the face or extremities,while
generalized are bilateral.
📍
🔸Hypoxic-ischemic
According to Common Age of Presentation:
AGES 1-4 DAYS:-
encephalopathy ,Drug withdrawal, maternal drug use of narcotic
or barbiturates, Intraventricular hemorrhage ,brianmal formation, Acute metabolic
🔸
disorders,TORCH infection, Inborn errors ofmetabolism, Pyridoxine dependency.
AGES 4th day -1st month:
- Infection Meningitis (bacterial) , tetanus , sepsis. TORCHEncephalitis,enteroviral,
Causes of Seizures ,Metabolic disorders ,Hypoglycemia, Hypocalcemia,Kernicterus, hyperbilirubinemia,
🔸
Status Epilepticus Inherited disorders of metabolism, CNSmalformation.
is defined as continuous convulsive activity or recurrent generalized convulsive 1 mon – 6th mon :-
🔸
seizure activity without regaining of consciousness ≥30 minutes. Infections , CNS malformation , inborn error of metabolism.
⚜️
Febrile statusepilepticus is the most common type of SE in children. 6th mon – 3 years:-
🔸
Types of status epilepticus Febrile seizures, CNS infection , metabolic , trauma , CNSdisorders.
1- convulsive status epilepticus The most common type of SE is (generalized Elder child:-
tonic,clonic, or tonic-clonic. Epilepsy , CNS infection , trauma , CNS disorders.
2-nonconvulsive status (focal with impaired awareness, absence) manifests as
aconfusional state, dementia,hyperactivity with behavioral problems,
fluctuatingimpairment of consciousness. with at times unsteady sitting or walking..
Refractory status epilepticus is SE that has failed to respond to
therapy,usuallywith at least two medications (such as a benzodiazepine and
🔶 Acute symptomatic seizures are a provoked seizures: defined as a clinical seizures occurring
another medication)
🔸
at the time of a systemic insult or in close temporal association with adocumented brain insult.
These seizures are caused by specific and transient pathophysiological abnormality in central
nervous system.
Etiology (mnemonic =(VITAMINS) the interval between occurrence of seizure varies according to etiology. seizure events can
1- Vascular ischemic (arterial or venous) stroke; intracranial hemorrhage happened within 1 week of acute brain insult in cases of stroke, traumatic brain injury, anoxic
2- Infection encephalitis; meningitis encephalopathy, or intracranial surgery; at first identification of subdural hematoma; at the
3- Traumatic acute head trauma presence of an active central nervous system (CNS) infection; or during an active phase of multiple
4- Autoimmune autoimmune encephalitis
5- Metabolic hypoglycemia hypocalcemia; hyponatremia; hypomagnesemia.
Malformations of brain
🔸
sclerosis or other autoimmun diseases.In addition,
a diagnosis of acute symptomatic seizure should be made in the presence of severe metabolic
derangements (documented within 24 h by specificbiochemical or hematologic abnormalities), drug
6- Inborn errors of metabolism: such as nonketotic hyperglycinemia in neonates and
mitochondrial encephalopathy with lactic acidosis folinic acid and pyridoxine and 🔸
intoxication or and withdrawal,or exposure to well-defined epileptogenic drugs. ;
the prognosis depends on the underlying disorder, including its reversibility or treatability and the
pyridoxal-phosphate dependency (these usually presentin infancy, but childhood onset is
also possible)
7- Intoxication (e.g.,tricyclic antidepressants) drug withdrawal or overdose in patients
🔸
likelihood of developing epilepsy from it.
Acute symptomatic seizures caused by (mnemonic =(VITAMIN)
V= vascular – cerebrovascular accident (CVA)
taking AEDs I= infection inside the CNS as meningoencephalitis
8- Neoplastic ( brain tumors) Status Epilepticus T= traumatic head injury
9- Systemic conditions (such as hypertensive encephalopathy,, renal or hepatic A= autoimmune
encephalopathy M= metabolic increase (sugar Ca Mg Na) or decrease Na
I= intoxication , inborn error of metabolism
N = neoplastic
Treatment of status epilepticus
🔸
Interventions for emergency department, in-patient setting, or prehospitalsetting.
A- 0 - 5 minutes stabilization phase:-
1. Stabilize patient (airway, breathing, circulation, disability-neurologicexam)
🔶 Febrile Seizures ( are provoked seizures)
The international league against epilepsy define febrile seizure as seizures occurring in childhood after one month to 5 years of age
2. Time seizure from its onset, monitor vital signs associated with:-
3. Assess oxygenation, give oxygen via nasal cannula/mask, considerintubation if respiratory assistance needed. a- febrile illness not caused by an infection of central nervous system
4. Initiate ECG monitoring b- no previous neonatal seizure or previous unprovoked seizures or other acute symptomatic seizure.
5. Collect finger stick blood glucose. If glucose <60 mg/dl then Children ≥ 2 years: 2 mL/kg D25W IV .Children < 2 American Academy of Pediatrics (APP) define Febrile seizures as seizures that occur:
years: 4mL/kg D12.5W between the age of 6 and 60 months with a temperature of 38C or higher,that are not the result of central nervous system infection or
6. Attempt IV access and collect electrolytes, hematology,toxicology screen, (if appropriate) anticonvulsant drug any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures.
🔸
levels.Does seizure continue? If yes start initial therapy phase.
B- 5 - 20 minutes initial therapy phase:-
A benzodiazepine is the initial therapy of choice Choose one of the following 3 equivalent first-line options with
it is the most common cause of convulsions in children and occurs in 2 - 5 % of all children between 6 months to 5 years of age. factors
like male predominance ,genetic factors, younger age as well as family history of FS are some of the notablefactors having association
with FS, Autosomal dominant inheritance pattern isdemonstrated in some families .
dosing andfrequency: Types:
1- Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13−40 kg, single dose. 1- simple febrile seizure
2- Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat doseonce.
🔥
3- Intravenous diazepam (0.15−0.2 mg/kg/dose, max 10 mg/dose, may repeatdose once.
If none of the 3 options above are available, choose one of the following:
🔶
2- complex or atypical febrile seizure
simple febrile seizure criteria:-
1- Fever (temperature of 38c or mor)
1-Intravenous phenobarbital (15 mg/kg/dose, single dose, 2- Generalized tonic-clonic seizure3- Duration few seconds to less than 15 minutes
2- Rectal diazepam (0.2−0.5 mg/kg, max: 20 mg/dose, single dose, 4- Usually not recur same day
3- Intranasal midazolam , buccal midazolamIf patient improves and return to baseline, then symptomatic medical 5- No focal neurological signs6- Focus of infection is present like URI7- No signs of increased intracranial pressure
🔸
care.Ifpatient not improved then start Phase 2
C- Phase 2 :-
20 - 40 minutes Choose one of the following second-line options and give as a single dose Intravenous fosphenytoin
8- Normal CSF findings and normal interictal EEG
9- Normal neurodevelopment of the child
Most patients with simple febrile seizures have a very short postictal state and usually return to their baseline normal
(20 mg PE/kg, max: 1500 mg PE/dose, single dose, OR Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, behavior and consciousness within minutes of the seizure.
single dose, OR Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single dose, If none of the options above
are available, choose one of the following (if not givenalready) Intravenous phenobarbital (15 mg/kg, max dose, )If 🔶 Complex or atypical febrile seizure criteria:
🔸
patient improved, then symptomatic medical careIf not improved continue 3rd therapy phase
D- 40- 60 minutes 3rd therapy phase Choices include: repeat second-line therapyor anesthetic doses of either
thiopental, midazolam, pentobarbital, or propofol (all with continuous EEG monitoring).
-Complex febrile seizures were defined as focal, prolonged (15minutes ormore)
-and/or recurrent within 24 hours or both
-has long period of postictal drowsiness.
If patient improved then symptomatic medicalcare -It may be accompanied by transient hemiparesis or Todd’s paralysis
-and may present in children with neuro-developmental problems.
-The most severe type of complex febrile seizure is known as febrile status epilepticus which means that febrile seizure occurs either
as continuous or intermittent without recovering consciousness for more than 30 minutes .
-it accounts for 25–52% of all cases of status epilepticus in children .
Etiologies of neonatal seizures: -Patients with febrile status epilepticus have a high chance to develop hippocampal lesions in the future.
🔹 1- Hypoxic-ischemic encephalopathy.
This is the most common cause of neonatalseizures, accounting for over 50% of cases. HIE can be global, as in perinatalasphyxia or
🔸 Risk factors for recurrence of febrile seizures
-Febrile seizures recur in approximately 30% of those experiencing a first episode, in50% after two or more episodes, and in 50% of
focal (i.e., arterial infarction). In perinatal asphyxia, the seizures occur
in the context of a newborn who has a history of difficulty during labor and delivery,often seen within the first 12 to 24 hours .seizures
📍
infants younger than 1 yr of age atfebrile seizure onset.
Major risk factors:
•Age < 1 year
🔹
are usually focal and may bemultifocal.
2. Intracranial hemorrhages (ICHs)
are responsible for 10% to 15% of neonatalseizuresa- In the term infant, primary subarachnoid hemorrhage (not due to extensionof a Seizures are possibly the most important and common indicator of significant neurologic dysfunction in the neonatal period.
•Duration of Fever <24 hr
📍
•Fever 38 - 39 c.
Minor risk factors:
deeper cerebral or intraventricular hemorrhage).seizures, usually on thesecond day of life.B-Subdural hemorrhages are related to large 🔷 Types of Neonatal Seizures: Acute Seizures in
•Family history of febrile seizure
•Family history of epilepsy
infant size, breech delivery, andinstrumentation.Presenting seizures are usually focal and occur in the first fewdays of life. c- In the
🔹
There are two main neonatal seizure types: electroclinical seizure and electrographic seizure only.
children
Acute symptomatic seizures •Complex febrile seizure
🔹
preterm infant, germinal matrix, intraventricular and parenchymalhemorrhages .Seizures typically occur after the first 3 days of life. 1- Electroclinical seizures associated with EEG changes can be categorized as •Day care
a- Motor seizures include automatisms, clonic seizures, epileptic spasms, myoclonic seizures, and tonic seizures. •Male gender
3-CNS infections account for about 5% of neonatal seizures. b- Non-motor seizures include autonomic seizures and behavioral arrestc- Sequential type for “events with a sequent of signs, symptoms, and EEG changes at •lower serum sodium at time of presentation
a- Congenital intrauterine infections, such as with cytomegalovirus (CMV),toxoplasma,rubella and herpes viruses may present early different times.” An example would be a sequence of tonic, then clonic, then automatisms, and autonomic manifestations with varying lateralization during one Having one risk factor, 25–50%; two risk factors, 50–59%; three or more risk factors, 73–100%.
(first 2 days) withseizures in severe cases.The clinical scenario may include microcephaly, poorintrauterine growth, prematurity, and other
skin, ophthalmic, and systemicfindings. 🔹
seizure.
2- Electrographic only. :
- seizures that appears only by EEG and no clinical seizure often seen in premature infants and Hypoxic-ischemic encephalopathy.
RISK FACTORS FOR OCCURRENCE OF SUBSEQUENT EPILEPSY
b- Postnatal sepsis, for example, with group B Streptococcus or Escherichia coli,isoften complicated by meningitis and may be Diferentiating seizure types based on clinical appearance alone is challenging. Thus in many cases, specifcally in sick neonates with a history of suspected
associated with seizures. In thissetting, the newborn has often been well for a couple of days, only to deterioratelater with seizures neurologic injury, continuous bedside EEG is necessary to make this distinction.Motor electroclinical Seizures
🔹
occurring after the first 48 to 72 hours. 1- Automatisms
Automatisms include transient eye deviations, nystagmus, blinking, mouthing, and abnormal extremity movements (rowing, swimming, bicycling, pedaling, and
4. Acute Metabolic Disorders. These rapidly remediable conditions are the focus ofthe initial investigations in neonatal seizures and stepping). Automatisms occur more commonly in premature than in full-term infants.
include hypoglycemia,hypocalcemia, hypomagnesemia, and hyponatremia. They account for 5% ofneonatal seizures. 2- Clonic seizures (Focal or multifocal) :-
a-Hypoglycemia :- definition of hypoglycemia is controversial, but reasonablethresholds for treatment are ˂40mg/dL (˂2.2 mmol/L) in Rhythimic movements of muscles groups They have both fast and slow components Occur with frequency of 1-3 jerks /sec. Commonly associated with EEG changes
the first 24 hours, and ˂50mg/dL (˂2.8 mmol/L) after 24 hours. Causes of neonatal hypoglycemia include .3- Tonic Seizures (focal or generalized ):-
Sustained flexion or extension of truncal or limb muscles (decerberated or decorticated posturing) ,Usually no EEG changes on generalized tonic seizures
decreased glucose supply, as in the premature and small-for-gestational-ageinfant, as well as disorders in which pathways of 4- Myoclonic Seizures (Focal, multifocal, and generalized types)
gluconeogenesis are deficient or suppressed Such as inborn errors of metabolism and increased utilization, such asin hyperinsulinemic Random, single, rapid contractions of muscle groups of the limbs, face, or trunk Typically not repetitive or may recur at a slow rate May be generalized, focal, or
states, most commonly seen in the infant of the diabeticmother. fragmentary May be provoked by stimulationPresumed pathophysiology: may be epileptic or nonepileptic and Predilection for flexor muscle groups, and Carry the
b-Hypocalcemia. Whole blood ionized calcium (iCa) is the best measure of calciumstatus in ill infants. Hypocalcemia is considered worst prognosis. Clinical Evaluation
5- Epileptic Spasms A detailed history should be extracted to identify whether the convulsion is febrileor afebrile; to find out the degree of fever
present when ionized Ca in terminfants or prematures ˃1,500 g birth weight is ˂4.4 mg/dL (˂1.1 mmol/L) and inpremature infants ˂1,500 g Epileptic spasms are sudden generalized jerks lasting 1-2 seconds that are distinguished from generalized tonic spells by their shorter dura- tion and by the fact that and its relationship to convulsion,duration of convulsion, type of seizure, the extent of postictal drowsiness, andvarious
at birth, ˂4.0 mg/dL (˂1 mmol/L). Most cases areasymptomatic. Symptoms of hypocalcemia include jitteriness, stimulus-inducedmuscle spasms are usually associated with a single, very brief, generalized discharge. associated systemic symptoms . Differential Diagnosis of fever and convulsion include:-
jerks, seizures, and rarely laryngospasm.Early-onset hypocalcemia occurs in the first 3 days of life and is associated withprematurity, Nonmotor electroclinical Seizures •Other relevant history includes history ofseizure, recent vaccination, attending daycare center, or prior treatment 1- Febrile seizure ( simple or complex)
1- Autonomic seizures withantibiotics or any drugs during this episode and any other symptoms related tomeningitis or encephalitis.
infants of diabetic mothers, intrauterine growth retardation, andperinatal asphyxia. Late-onset hypocalcemia can occur because of 2- CNS infection (meningitis, encephalitis)
hypoparathyroidism, the feeding ofhigh-phosphate formula , hypomagnesemia.
c-Hypomagnesemia. The most common cause is transient neonatalhypomagnesemia. It causes parathyroid hormone resistance and, so,
typically accompany additional seizure types and are rarely seen in isolation.involve fuctuations in autonomic system func- tion, including alterations in the
cardiovascular, vasomotor, pupil- lary, and thermoregulatory function. Teseseizures may include heart rate changes, hypertension episodes, and apnea.
2- Behavioral Arrest
🔸
•Past history and family history of febrile or afebrileseizures, detailed birth and development history are also important.
Febrile seizures ofen occur in the context of otitis media; roseola and human herpes virus (HHV) 6 infections; and infections
with norovirus, parecho virus,enteroviruses, Shigella, or similar agents, making the evaluation more demanding.In patients with
3- Fever triggering in children with epilepsy
4- Other precipitants of seizure in children with fever
(electrolytes imbalance ,hypoglycemia, head trauma ,
causeshypocalcemia. Hypomagnesemia must be corrected before the hypocalcemia canbe corrected .Levels ˂1.4 mg/dL (˂0.6 mmol/L) Behavioral arrest seizures include cessation of activity or immobiliza- tion. Tis seizure type is rarely seen in isolation and can be seen as a component of sequential
seizures.Seizures Versus Jitteriness:- Jitteriness or tremors in neonates differ from seizures by the following characteristics:- 🔸
febrile status epilepticus, HHV-6B (more frequently) and HHV-7infections may account for 30% of the cases.
The child should be monitored at the time of admission.
intoxication)
🔹
are considered low.
5-Malformations/structural lesions.
5% of neonatal seizures are caused bycerebral dysgenesis.Cerebral dysgenesis can cause seizures from the first day of life. This is most
● Fast movements ( 4- 6/sec)
● Provocated by stimulation
A thorough general and neurological examination includes cranial nerves, motor systems, and fundal examination needs to be
completed to identify the cause of fever and to exclude possible differential diagnoses such as meningitis (bulging fontanelle,
neck stiffnessor kerning sign and Brudzinski’s sign) and encephalitis.
● Ended by holding or flexion of the limbs
likelywith the more severe disorders, such hemimegalencephaly, , and polymicrogyriaslissencephaly. (Seizures are often very refractory ● No abnormal eye movemens
🔹
to medications.)
6. Inborn errors of metabolism. (IEM):-
Typically caused by an enzyme defect inthe metabolic pathways of carbohydrates, proteins, or fat, In these disorders,infants initially
Investigations:-
🔶
🔸 Lumbar Puncture:
1- differentiating febrile seizures from serious infection like bacterial meningitis isessential but remains clinical dilemma
for many clinicians in the emergencysetting. children between the ages of 6 and 18 months are especiallyproblematic as
appear well due to the benefits of placental clearance of toxins untilbirth and only become encephalopathic and have seizures after 2 specific localizing signs and symptoms of meningitis may notmanifest or be minimal so some clinician advocating routine
to 3 days.Biochemical markers for these disorders include hypoglycemia,metabolic acidosis,hyperammonemia,and there is family history
🔸
lumber puncture inall infants less than 18 months of age with first febrile seizure irrespective ofclinical findings.
🔹
of similar illness or death. 2- Due to the low risk of meningitis in children with first simple febrile convulsionin areas with good immunization
coverage American Academy of pediatrics recommends the following indications:-
7- Pyridoxine dependency, although rare, is an important cause of neonatalseizures as treatment is available. A-should be performed for:
A test dose of pyridoxine 100 mg IV, with EEG,and cardiorespiratory monitoring, resulting in immediate seizure cessationand resolution of 1- all infants younger than 6 mo of age who present with fever and seizure. Treatment
EEG abnormalities within hours, is diagnostic. 2- at any age if there are clinical signs or symptoms of concern. For parents and caregivers, witnessing a seizure can be a distressing experience,signifcantly impacting their quality of
3- febrile status epilepticus . life.The important steps in treatment of febrile seizures are:-
DIAGNOSIS: 4- complex febrile seizure in patients with a suspected CNS infection. 1- Manage acute febrile seizure and acute illness.
simply taking the prenatal and postnatal history and performing an adequatephysical examination .Careful neurologic examination of the infant might uncoverthe B- in a infants between 6 and 12 months of age LP should be strongly considered if:- 2- Determine risk factors for recurrence and estimate risk of recurrence of thefebrile seizures.
cause of the seizure disorder . 1- not immunized against Haemophilus influenza type b and Streptococcus pneumonia. 3- Determine risk factors for later epilepsy.
🔶
Examination of the retina might show thepresence of chorioretinitis, suggesting a congenital TORCH infection. 2- the immunization status is unknown. 4- Counsel parents about risk of recurrence and how to provide first aid andmanage fever.
An unusualbody or urine odor suggests an inborn error of metabolism. 3-children have been pretreated withantibiotics.( mask the signs and symptoms of meningitis) A- Treatment of an acute episode:-
Investigations The approach to investigations should be individualized with an emphasis onearly identification of correctable disorders and directed according to the Neonatal Seizures C- child between 12 and 18 months should also be considered for lumbar punctureas there are usually slight symptoms
of meningitis clinically. 🔸
In most cases, simple febrile seizure spontaneously ceases within 2-3 min, and does not require treatment.
🔸 Search for cause of fever.
🔹
clinical findings.
🔹 1- Blood:- should be obtained for determinations of glucose, calcium, magnesium,electrolytes, and blood urea nitrogen ,bilirubin ,blood culture, urine culture. D- children above 18 months, a lumbar puncture is needed in the presence ofclinical signs and symptoms of
meningitis (such as neck stiffness, Kernig andBrudzinski signs) or if the case suggests intracranial infection . 🔸 Antipyretics:
decrease the discomfort and not reduce the risk of having arecurrent febrile seizure. ( seizure often occurs as the
🔹 2-lumbar puncture:- indicated in neonates with seizures due to sepsis ,neonatalmeningitis , intracranial hemorrhage, some inborn errors of metabolism.
3- General metabolic screening:- screening for inborn errors of metabolismincluding serum ammonia ,arterial blood gase for acidosis and other
🔶 .🔸 ( ACETAMINOPHEN 10–15 mg/kg/dose PO/PR Q4–6 hr; max. dose: 90mg/kg 24 hr OR IBUPROFEN 5–10
temperature is rising or falling)
🔹
investigationsshould all be considered and the approach modified by the individual case history.
4-NeuroimagingCranial ultrasound examination can be accomplished at the bedside and may identifyintracranial hemorrhage, especially in the premature.Head
Electroencephalogram
not need to be performed as part of the evaluation If the child is presenting withthe first simple febrile seizure and is otherwise
🔸
mg/kg/doseQ6–8 hr PO; max. dose: 40mg/kg/24 hr PO)
Educated parents about the features of febrile seizures and how to handle aseizure acutely, and about the risk of
🔹
CT, and especially brain MRI are more helpful in Infants with focal seizure andstructural abnormalities, intracranial hemorrhage.
5- EEG
neurologically healthy because:-
1- not predict the future recurrence of febrile seizures or epilepsy even if the resultis abnormal. recurrency and subsequentepilepsy(see the tables).
a-can show epileptiform activity (e.g., sharp waves) between the seizures (suggestingan increased risk for seizures) and confirm electrographic seizure activity if a
clinicalseizure is recorded. 🔻
2- Often nonspecific if performed within 2 wk of a febrile seizure.
indicated in the following conditions:- 🔸
❖ If the seizure lasts for longer than 5 min.
Rectal diazepam 0.2mg – 0.5 mg/ kg ( maximum 10 mg) or buccalmidazolam (0.3 mg/kg, max 10mg) can be used at
b-EEG monitoring is often necessary because electrographic seizures can occurwithout observed clinical signs (electroclinical dissociation). a- if the risk of epilepsy is highly suspected (see the table of the risk of epilepsy)
b- if patient does not recover immediately from seizure to distinguishedbetween ongoing seizure activity and postictal 🔸Instruct on the appropriateness of anticonvulsive therapy, whenprescribed, including the relevant side effects.
home as rescuemedication.
TREATMENT OF NEONATAL SEIZURES
state (postictal state ofsimple febrile seizure usually minutes
c- febrile status epilepticus.
🔶B- Prevention seizures with risk of recurrence:-
🔶
🔸 A- treatment of common acute metabolic derangements.
1-hypoglycemiaa-initial treatment 200 mg/kg of glucose over 1 minute, to be followed bycontinuing therapy .This initial treatment is equivalent to 2 mL/kg of dextrose 10%water (10% D/W) 🔶 Blood Studies
❖ prophylactic antiepileptic therapy is not recommended for simple febrileseizures due to the benign prognosis and
the risk of side effect of this drugs.
❖ If there is history of frequently recurring short febrile seizures(3 or more in6mo or 4 or more in year). or in patients
infused intravenously.b- Continuing therapyInfusion of glucose at a rate of 6 to 8 mg of glucose/kg /minute. ( 10% D/W at a rate of 86.4 mL/kg per day or 3.6 mL/kg per hour gives 6 mg/kg per 1- Simple febrile seizure. Serum electrolytes, calcium, phosphorus, magnesium, complete blood count not routinely with febrile status epilepticus orrecurrent complex febrile seizure, Give intermittent prophylaxis during thefebrile
minute of glucose.) recommended: the decision on whether or not to perform the tests should exclusively aim at identifying the cause of fever illnesses(2-3days):-- intermittent oral clonazepam (0.01 mg/kg every 8-12 hr up to amaximum dose of 1.5 mg/day)- or
Recheck glucose level 20 to 30 minutes after IV bolus, and then hourly until stable,to determine if additional therapy is needed. Additional bolus infusions of 2 mL/kgof 10% D/W may be needed. (search for fever etiology ) oral (0.3 mg/kg) or rectal (0.5 mg/kg) diazepam 8 hourly can begiven
🔸
If glucose is stable and in acceptable range, feedings may be continued and theglucose infusion tapered as permitted by glucose measurements prior to feeding.
2-Hypocalcemia Emergency calcium therapy (for active seizures ) consists of 100 to 200 mg/kg of10% calcium gluconate (9–18 mg of elemental calcium/kg) by intravenous infusionover 10
to 15 minutes.Monitor heart rate and rhythm and the infusion sitethroughout the infusion.
● Blood glucose is needed to measured initially or subsequently if there isprolonged postictal obtundation or poor oral intak.
● serum electrolyte are needed if clinically indicated (eg dehydration).( lowserum Na associated with a higher risk of
recurrence of the febrile seizurewithin the following 24 hr.)
Repeat the dose in 10 minutes if there is no clinicalresponse. Following the initial dose(s), maintenance calcium should be giventhrough continuous intravenous infusion. 200–800 mg/kg/24 hr ÷ 2-Complex febrile seizure Performance of blood chemical tests: decision is related to clinical condition.
Q6 hr .IVinfusion: Do not exceed 120–240 mg/kg/hr with a max. concentration of 50mg/mL. Therapy with calcium is usually adequate for most cases. In some casesconcurrent therapy with
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magnesium is indicated.
Before you start calcium parenteral therapy the following precautions must beconsidered:-
🔶 CT or MRI (Indicated in febrile status epilepticus)
a-Rapid intravenous infusion of calcium can cause a sudden elevation of serumcalcium level, leading to bradycardia or other dysrhythmias. ❖ is not recommended after first simple febrile seizure.
b- Infusion by means of the umbilical vein may result in hepatic necrosis if thecatheter is lodged in a branch of the portal vein. ❖ needs to be individualized in complex febrile seizures (eg.if the childneurologically abnormal)
c. Rapid infusion by means of the umbilical artery can cause arterial spasms and, atleast experimentally, intestinal necrosis and thus, is generally not indicated.d. Intravenous calcium
solutions are incompatible with sodium bicarbonate sincecalcium carbonate will precipitate.
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e. Extravasation of calcium solutions into subcutaneous tissues can cause severenecrosis and subcutaneous calcifications.
3- hypomagnesemia Hypocalcemia seizures with concurrent hypomagnesemia should include treatment for the hypomagnesemia. The preferred preparation for treatment
ismagnesium sulfate. 🔶 Breath-Holding Spells
The 50% solution contains 500 mg or 4 mEq/mL. Correctsevere hypomagnesemia (˂1.6 mg/dL) with 50 to 100 mg/kg of magnesium sulfate intravenously given over 1 to 2 hours.
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When administering intravenously, infuseslowly and monitor heart rate. The dose may be repeated after 12 hours. Obtainserum magnesium levels before each dose. 🔸
usually begin between 6 and 18 months of age. Due to immaturity of theautonomic system and occur in two diferent forms.
1- pallid breath-holding spell,:-
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B- treatment of other underlying causes (eg . sepsis, IEM, electrolyte imbalance).
Anticonvulsant medication 🔸
a silent cry with marked pallor caused byvasovagal reflex lead to refex vagal-cardiac bradycardia and asystole.
2- the cyanotic or, “blue,” breath-holding spell:-
Episodes usually start with a cryleading to prolonged expiratory apnea and intrapulmonary shunting isresponsible for the cyanotic
When anticonvulsant treatment is indicated, phenobarbital is the drug mostcommonly used as first-line therapy. Other first-line options includebenzodiazepines (diazepam, lorazepam) and
phenytoin or, if available, its prodrugfosphenytoin. episodes.
i. Phenobarbital is the initial drug of choice. Education and reassurance of the parents is usually all that is needed, as theseepisodes are, as a rule, self-limited and outgrown
It is given as a loading dose of 20mg/kg IV. If seizures continue, additional loading doses of 5 to 10 mg/kg IV maybe given as needed to control seizures until a cumulative dose of 40 mg/kg is within a few years. However,treatment of coexisting iron deficiency is needed if it is present. Education of the parents on how to
handle more severe spells by first-aid measures is important
reached.
A maintenance dose of 3 to 5 mg/kg/day PO or IV divided bid shouldbe started 12 to 24 hours after the loading dose. During loading doses of phenobarbital, the newborn needs to be
monitored closely for respiratory depression.
🔶 Syncope
Syncope can present with drop attacks triggered by a sudden cutting off of oxygento the brain, lead to generalized convulsions,
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The use of phenobarbital can be associated with electroclinical dissociation,where electrographic seizures persist despite the resolution of clinical seizures,after the drug is give Subsequent termed anoxic seizures.
EEG monitoring is therefore imperative to rule out subclinical seizure activity. 1- Vagal syncope.
ii. Phenytoin The loading dose is 15 to 20 mg/kg IV over 20 minutes diluted innormal saline 1 mg /1ml (don,t dilute in dextrose) administered at no greaterthan 1 mg/kg/minute (toavoid A- Vasovagal (neurocardiogenic) syncope most common mimickers of generalized tonic clonic seizures and is usuallytriggered
cardiac arrhythmia and hypotension)followed by a maintenance dose of 4to 8 mg/kg/day divided q8h. Fosphenytoin It is highly soluble in water and canbe administered very safely intravenously by dehydration, heat, standing for a long time without movement, hotshowers, the sight of blood, pain, or sudden stress. History is
and intramuscularly, without causinginjury to tissues. Fosphenytoin is administered in phenytoin equivalents (PE). Conditions That usually the clue todistinguishing syncope from epileptic seizures. There is initially pallor and sweatingfollowed by blurring of
The usual loading dose of fosphenytoin is 15-20 PE/kg administered over 30min. Maintenance doses of 4-8 PE/kg/day can be given. vision, dizziness, nausea, and then gradual collapse withloss of consciousness
iii. Benzodiazepines Diazepam, lorazepam, and midazolam Clonazpam. Onset ofaction is within minutes however, duration of action is longer for lorazepam (upto 24 hours). Lorazepam is Mimic Seizures B- Vagovagal syncope is triggered by swallowing or vomiting, Sudden coldexposure to the face or to the body and can progress
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often used in the acute treatment of neonatal seizures; it is distributed to the brain very quickly and exerts its anticonvulsanteffect in less than 5 min. It is not very lipophilic and does not clear to convulsive seizure ifthe asystole is sufficiently prolonged.
out from thebrain very rapidly. Its action can last 6-24 hr. Usually, it does not causehy potension or respiratory depression. 2- Cardiac Syncope Long QT syndromes (LQT) can cause life-threatening “pallid” or white syncope.Accompanying this are
The dose is 0.1 mg/kg when used foracute treatment of seizures, and 0.05 mg/kg (range: 0.02-0.10 mg/kg) every 4-8 ventricular arrhythmias,
hr when used as scheduled medication a Diazepam may be more effective as acontinuous infusion. Diazepam dose is 0.3 mg/kg IV. All family members of an affected LQT syndrome individual should be investigated.
Midazolam doses used have been in the range of 0.05-0.15 mg/kg as an initial intravenous bolus, with acontinuous infusion of 0.5-1 μg/kg/min intravenously that can then be gradually titrated Affected individuals need insertion of cardiac defibrillators, and their familiesshould be taught CPR. As a rule children with new
upward, if tolerated, every 5 min or longer, to a maximum approximately 33 μg/kg/min (2 mg/kg/hr).if you used high dose infusion it needintubation and mechanical ventilation. Clonazpam 0.1- onset seizure disorder should getan electrocardiogram (ECG) to rule out LQT syndrome masquerading as seizuredisorder.
0.2 mg/kg iv bolusfollowed by iv infusion of 10- 30 microgram/kg/hr. Cardiac syncope is usually sudden without the gradual onset and the symptomsthat accompany vagal syncope. Aortic stenosis
can cause sudden syncope at theheight of the exercise (usually hypertrophic), or directly at the end (usuallyvalvular) and, if
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suspected, warrants an echocardiogram.
Other conditions mimic seizure
1) Normal physiologic phenomenon Sleep myoclonus
2) Exaggerated physiologic reaction Startle
3) Benign paroxysmal vertigo
4) Behavioral :- Day dreamNight terrorsShuddering
5) Psychatric :-Pseudoseizure and Panic attack
by fatema okoff
