Seizures

1. Seizures Julie Jaffray, MD Emily Pollakowski, MD

2. What are Seizures • Transient • Involuntary • Alteration in consciousness, behavior, motor activity, sensation or autonomic function • Due to abnormal electrical neuronal discharge in cerebral cortex • Signs and symptoms depend on location of discharge

3. Types of Seizures • Febrile • Partial • Simple partial • Complex partial • Generalized • Absence • Myoclonic (muscle twitching) • Clonic (rhythmic shaking) • Tonic (rigid contracture) • Atonic • Tonic-clonic

4. Febrile Seizures • Seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of the central nervous system • No previous neonatal seizure or previous unprovoked seizures • Vast majority are benign and rarely cause brain damage • Usually due to a rapid rise in temperature

5. Febrile Seizures • 90% of febrile seizures occur between 6 months and 3 yrs of age • 2-5% children will have a febrile seizure at some point • Simple febrile seizures (70-75%) • Single, brief (<15min) generalized seizure during fever without intracranial infection or other causes and self resolves • Complex febrile seizures • Lasts >15 min, focal, reoccurs within 24 hours

6. Simple Partial Seizures • Onset of seizure in a limited area, or one cerebral hemisphere • No impairment of consciousness • Highest incidence after 1 year of life • Risk of reoccurrence is higher than with generalized seizures • Can be sensory, motor or autonomic • Any structural lesion can causes SPS • Vascular, meningitis/encephalitis, trauma, tumors, hypoxic insult, postsurgical changes, metabolic/electrolyte shifts, endocrine disorders, meds/toxins

7. Complex Partial Seizure • Starts focally within the brain then causes impairment of consciousness • Most commonly a manifestation of temporal lobe epilepsy • Typically last 30 sec-2 mins • Patient can describe an aura • Can be autonomic, simple motor, complex motor, negative (aphasic, atonic, hypomotor)

8. Absence Seizures • Type of generalized seizure-not conscious • Brief, usually frequent throughout the day (in childhood absence) • Appear later in childhood • Staring spells, decline in school performance • Hyperventilation can provoke a seizure

9. Tonic-Clonic Seizures • Occurs in several epilepsy syndromes • Initiated by 3 mechanisms • Abnormal response of a hyperexcitable cortex • Primary subcortical trigger • Abnormal innervation from subcortical structures • May have a prodrome hours to days prior to seizure • Mood changes, light headedness, anxiety, sleep disturbance, difficulty with concentration • Postictal state • Variable period of consciousness, gradually wakens usually confused

10. Status Epilepticus • Any continuing type of seizure, but usually refers to a generalized convulsive state • Seizure lasting more than 30 mins • Continuous or multiple seizures without gaining consciousness • Can lead to hypertension, tachycardia, cardiac arrhthmias and hyperglycemia • Mortality is 20%

11. Other Seizure Disorders • Neonatal seizure • Can be tonic, clonic, myoclonic or subtle (blinking, chewing, bicycling, apnea-due to immature CNS) • Usually a symptom of acute brain disorder • Hypoxic-ischemic encephalopathy • Intracranial hemorrhage/infarction • CNS infection • CNS malformation • Metabolic (hypoglycemia, hypocalcemia, toxins) • Inborn errors of metabolism • Infantile Spasms • Head nodding and flexion or extension of trunk and extremities • Often in clusters • Onset 2 months, peak 4-6 months

12. Causes to think about • Intracranial infection (meningitis, encephalitis) • Intracranial tumor (benign or malignant) • Injury causing intracranial hemorrhage • Metabolic disturbances (hypoglycemia)

13. Acute Seizure Management • Status Epileptus • Defined as > 30 minutes of continuous seizure activity or 2 or more sequential seizures in 30 minutes without full recovery of consciousness between seizures • Prepare for status with every seizure you witness -Medication dosing -Differential diagnosis

14. Acute Seizure Management,Minutes 0-5 • Before anything else…A B C! • Airway • Breathing • Circulation • Stabilize patient • Establish access and obtain labs

15. ABCs • Airway -Appropriate positioning -Open airway, using head-tilt/chin-lift -If suspected head/Cspine trauma, jaw thrust -Rule out obstruction

16. ABCs • Breathing -Evaluate air exchange -Look and listen -Abnormal chest wall dynamics -If actively seizing: oxygen -If hypoventilating: ambu bag ventilation -Concern for aspiration

17. ABCs • Circulation -Rate Goal HR >100bpm (infant), >60bpm (child) -Rhythm -Assess pulses (central and peripheral) -Assess capillary refill -IV access, send off labs

18. Acute Management,Minutes 5-15 • Diazepam 0.5mg/kg IV/PR (max 6-10mg) • Check FSBS (if possible) • D10 bolus, 5mls/kg -use 20ml syringe: 4ml D50 + 16ml NS -repeat for full weight-based dose • Repeat diazepam if still seizing 5-10 minutes later • Think about next step

19. Acute Management, Minutes 15-35 • Phenobarbital • Loading dose: 15-20mg/kg IV, then 5mg/kg q 30 minutes to max 30mg/kg • Maintenance: 5mg/kg/day IV, either BID or daily • Phenytoin/Fosphenytoin • Loading dose: 15-20mg/kg IV • Maintenance: 5mg/kg/day IV, divided BID, may increased to 8mg/kg/day

20. Watch out! • Important to monitor closely during administration of above medications • Vitals (RR, HR, BP) • Level of consciousness

21. Side Effects • Diazepam -Respiratory depression -Hypotension • Phenobarbital -Respiratory depression -Hypotension • Phenytoin -Hypotension -Arrythmias

22. Overall Goals • Stabilize the patient • Stop the seizure • Determine etiology (labs, imaging) • Eliminate precipitating factors • Reverse correctable causes • Observe • Determine long term plan and need for daily AED

23. Long Term Management • Too many drugs to remember! • Choice of AED depends on seizure type • Start with monotherapy, as 75% children with epilepsy will be, fully controlled • Polypharmacy is more expensive, decreases compliance, increases risk of toxicity