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Seizure and status epilepticus in children

Seizure and status epilepticus in children. Chapters 125 and. Seizure definition. Episodic alteration in: Motor activity Behavior Sensation Autonomic function Abrupt change in brain function Epilepsy: recurring seizures with identifiable or reversible cause. Identifiable Causes.

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Seizure and status epilepticus in children

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  1. Seizure and status epilepticus in children Chapters 125 and

  2. Seizure definition • Episodic alteration in: • Motor activity • Behavior • Sensation • Autonomic function • Abrupt change in brain function Epilepsy: recurring seizures with identifiable or reversible cause

  3. Identifiable Causes • Idiopathic 25-50% • Metabolic abnormality (hypoglycemia) • Complications of disorders (ex sickle cell) • Toxic ingestions • Viral and bacterial infection • Cerebral abnormality or shunt malfunction • Shaken baby syndrome

  4. Antiepileptic Drugs • Gabapentin • Lamictal • Topamax • Gabitril • Trileptal Depacon Cerebyx Zonegran Keppra

  5. Ketogenic Diet • Seizure control improved for resistant epilepsy by severely restricting glucose and increasing fat intake • In ED, MUST maintain ketosis • No glucose infusion • No Rx with measurable carbohydrate content • Complications: • Renal calculi • Pancreatitis

  6. First Seizure • History • FHx, underlying neuro abnl, Hx trauma, focal or complex seizure • Exam • Trauma, abnl head size, infxn, injury • Labs • CT if focal deficits or concern for trauma/abuse • LP if suspicion of meningitis • Disposition

  7. Breakthrough Seizure Causes: • Low anticonvulsant blood level • Change in habits (sleep, stress, meds) • Progression of underlying cause Treatment: • May give current meds or correct electrolytes • Consult neurology before adding medication

  8. Febrile Seizure • Seizure associated with fever but without evidence of intracranial infection or defined cause • Occurring between 6m and 5yrs • Identify and treat any sources of infection • Check glucose • Consider LP • Treat fever • Observe in ED until at neuro baseline

  9. Chronic AED prophylaxis • Phenobarbital load 15mg/kg IV then 4-6mg/kg/d • 1. Complex febrile seizures • 2. Pre-existing neurologic deficit • 3. Onset before 6 months • 4. Repeated seizures in the same illness • 5. Prior nonfebrile seizures • 6. More than 3 febrile seizures in 6 months

  10. Neonatal Seizures • Multifocal or fragmentary seizures more common • Autonomic dysfunction may be only symptom • Immature brain prevents the propagation of the seizure

  11. Infantile Spasms • Presents at 3-9m and as last as 18m. • Concurrently exhibits regression in develpmt • Very brief or repetitive spasms • Mental retardation 85% • Refer to neurologist

  12. Head Trauma and Seizures • Immediate posttraumatic seizure • Due to traumatic depolarization of neurons • Risk of recurrence is minimal • Early posttraumatic seizure • Occurs within 1wk • Epilepsy in 20-25% • Fosphenytoin recommended • Late posttraumatic seizure • 1wk-10yrs later • 40% focal or partial; 50% temporal • 70% recurrence rate

  13. Status Epilepticus • Continuous seizure lasting 30 min. • Absence (petit mal), child appears dazed and may have repetitive eye blinking • Cell death from increased metabolic demands & exhaustion from continuously firing neurons • Start with lorazepam, then fosphenytoin, phenobarbital (repetitive), then lidocaine or propofol

  14. Medication Side Effects • Lethargy • Rashes (Steven-Johnson Syndrome) • Toxicity from drug • Chorea • Phenytoin • Folate deficiency with macrocytic anemia, osteomalacia, neutropenia, neuropathy, lupus rxn, myasthenic weakness • Valproic acid • Hepatic failure/pancreatitis • thrombocytopenia

  15. Altered Mental Status • Spectrum: confusion-lethargy-stupor-coma • Both cerebral cortices must be affected to cause AMS • Three pathologic conditions: • Supratentorial mass lesion • Subtentorial mass lesion • Metabolic encephalopathy

  16. Differential Diagnosis for AMS • Alcohol • Acid-base and metabolic disorders • Dysrhythmia/cardiac disorders • Encephalopathy • Endocrinopathy (Addisons or thryoid) • Electrolytes • Insulin • Intussusception • Opiates • Intracerebral vascular disorders • Poisoning • Psychogenic • Seizure • Uremia • Trauma • Tumor • Thermal • Infection

  17. Headache • Primary h/a: • Migraine, tension, etc. • Less concerning • Secondary h/a: due to anatomic problem • Fever most common cause of headache • Acute post-traumatic headache • Intracranial mass • Infection/sinusitis/dental abscess • Systemic disorder (lupus cerebritis) • More concerning and deserve workup

  18. Evidence Based Studies show… • High percentage of positive findings with • First headache • Worst headache • Change in pattern of chronic headache • Associated with seizure, fever, or meningeal signs • AMS • Focal neurologic abnormality

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