Seizure recognition, seizure types, First Aid and Safety

1. Seizure recognition, seizure types, First Aid and Safety Charuta Joshi MBBS, FRCPC Director of pediatric epilepsy UIHC

2. Objectives At the end of this lecture the participants will be able to: Define a seizure Recognize different types of seizures Define epilepsy Know basic steps involved in seizure first aid Name 2 different medications used on the site to treat seizures in the prehospital setting Be familiar with ketogenic diet as therapy for seizures

3. What is a seizureSeizure recognition • A clinical manifestation of : • Abnormal • Excessive • Paroxysmal • Electrical discharge in neurons

4. Seizure recognition • Stereotyped • Repetitive • If unsure video tape events • Ask pediatrician to see

5. Seizure recognition • Spectrum of findings Generalized seizures Complex partial seizures Simple partial seizures

6. Seizure recognitionsimple partial seizures • Localization

7. Seizure recognitionGeneralized • Absence • Myoclonic • Tonic • Generalized tonic clonic

8. How important is it to be sure about a seizure

9. First seizure clinic results • 127 children • 94 were given diagnosis of epilepsy in first seizure clinic • 36 had suffered at least one previous seizure ( 15 unrecognized by family as a seizure) • 31 – non epileptic events • Unclassified in 2

10. Differential diagnosis

11. Investigations after a first unprovoked seizure

12. Investigations

13. Yield of neuroimaging(Shinnar et al 2001)

14. What is epilepsy • Tendency to have recurrent, unprovoked seizures • 2 or more unprovoked seizures separated by 24 hours

15. Questions parents have after seizures • Will it happen again? • How long do I have to wait for a recurrence? • Could my child die during a recurrence? • Could there be brain damage due to recurrence • If medication treatment is delayed will there be change in long-term chance of permanent remission?

16. Recurrence risks • Recurrence rate at 2 years 40-50% • Half the recurrences are within 6 months of initial seizure • 80% of 5 year recurrence risk stabilizes by 2 years out

17. Risk factors for recurrence • Remote symptomatic etiology • Abnormal EEG ( any spikes, generalized spike wave, focal or generalized slowing) • Occurrence of seizure during sleep state (increases chance of recurrence)= lower morbidity than during daytime seizure • Risk of recurrence after 2 seizures is 80%

18. Do you treat a first seizure • Treatment reduces the risk of a second seizure by 50% at 2 years • Immediate treatment DOES NOT reduce risk of long term seizures • Treated and untreated groups have a 64% chance of 5 year remission at 10 years (MESS study) • Risk of toxicity, allergic reaction, cognitive side effects

19. Risks of morbidity/ mortality due to seizures- could my child die?? • 692 children in Nova Scotia ( Camfield 2002) • Followed =20 years • 26 deaths • 1 from status • 1 from SUDEP as an adult at age 22 years

20. Could my child die • Dutch study of childhood epilepsy ( Callenbach 2001) • 472 children followed for 5 years • 9 deaths • None from epilepsy • Connecticut study ( Berg 2004) • 613 children followed for 7.8 years • 13 deaths • 1=status • 1=SUDEP

21. When does immediate treatment matter • When risks of recurrent seizures outweigh benefits of withholding treatment ( adults) • Cyanotic congenital heart disease in a child

22. Seizure first aid • ABCs • Stay calm • Don’t leave patient alone • Lateral position if possible • Don’t restrain • Nothing in mouth • Call 911

23. Seizure safety • Maximize quality of life • Water safety • Safety on roads • High structures • Medic alert, seizure beds, seizure dogs, baby monitors

24. Seizure precautions • Regular sleep • Alcohol • Infections • Photic stimulation • Substances of abuse Sports participation has not been shown to increase risk of seizures

25. Prehospital treatment of seizures Operational definition of status Time definition of convulsive status epilepticus Most seizures stop Optimum time to start therapy 0 30 5 15

26. Medications used for prehospital treatment • Diazepam • Midazolam • Lorazepam

27. Prehospital treatment

28. midazolam

29. Lorazepam • 2mg/ml Intensol • Indicated for anxiety

30. Faves…

31. Moving on to a different discussion now…

32. Ketogenic diet • UIHC= The only center in the state • 30-40 active patients • Dedicated dietician Karla Mracek • Dedicated ARNP Tiffany Rickertsen

33. Historical anecdotes History Mr MacFadden Physical culture • Mac Fadden 1899- magazine Physical Culture • Medical profession= Organized fraud • People who follow MacFadden’s rules would live to 120 years • Since much of the body’s energy is wasted in digesting food, if no food is provided, more energy can be applied to recovering health • Dr Conklin-osteopath in Battlecreek , Mi • Used diet in epilepsy

34. Historical anecdotes • Conklin’s work( intestinal epilepsy- toxin release from glands= seizures) • Conklin’s fast 18-21 days ( or as long as they could stand it)

35. Historical anecdotes • Dr Geyelin worked at Johns Hopkins= confirmed Conklin's findings • Dr BJ Wilder= fat can be used to break fast= no seizures

36. Charlie foundation Charlie Foundation Movie • Mr Jim Abrahams • Sought help from Johns Hopkins for his son Charlie • Seizure free today after several medications and neurologists

38. Since then…

39. Indications

40. Mechanisms of actionNot exactly known • Ketone bodies= antiepilepsy properties • PUFAs= membrane stabilization • Antioxidative/ antiinflammatory • Uncoupling of oxidative phosphorylation( better energy utilization)

41. Types of ketogenic diet • Classic ketogenic diet= 4:1 ratio • MCT oil diet ( less restrictive) • Modified Atkins diet=15-20 gm carbs/day • Low Glycemic index diet=60 gm carbs/day

42. Ketogenic diet Most kids not fat… Results 50-60% improve Almost 100% improve – Doose , GLUT1 Contraindicated Fatty acid oxidation defect

43. Thank You !!