Please enable JavaScript.
Coggle requires JavaScript to display documents.
Afebrile seizures (Age:
Neonatal seizures - rarely part of benign…
Afebrile seizures
Age:
- Neonatal seizures - rarely part of benign epilepsy syndrome, usually underlying severe cerebral dysfunction. Will not be generalised tonic clonic because brain not mature enough to synchronise
- Infantile - challenging epilepsy, needs specialist. Includes differential of: benign myoclonic epilepsy of infancy (no further investigation/tx), West's syndrome = classical triad ofinfantile spasms - salaam attacks, hypsarrhythmia on EEG, developmental regression/delay, myoclonic epilepsy of infancy, myoclonic astatic epilepsy = likely to be unresponsive to AEDs, use of ketogenic diet
Childhood absence epilepsy 4-12yos onset
stare momentarily, looks a bit like daydreaming, may twitch eyelid/hand
lasts a few seconds (not longer than 30s)
child has no recall
may realise they have missed something on regaining consciousness
only 2% of childhood epilepsy
Good prognosis - 95% remission in adolescence
Can be induced by hyperventilation
2/3rds are female
Lennox-Gastaut** 1-3 years old onset
Lots of different fits - DROP attacks**, tonic and atypical absences
Developmental arrest or regression
Behaviour disorder
Complex neuro problems in history often, infantile spasms, poor prognosis
WEST syndrome: 4-6 months onset, diagnosis by 1yr.
Flexor spasms of head trunk and limbs - extension of arms 'salaam attack'
last 1-2s, can happen in bursts, on waking
deterioration of social interaction
hypsarrhythmia on EEg
tx with vigabatrin or corticosteroids
Benign epilepsy with centrotemporal spikes:4-10 years old, onset in primary school
tonic clonic fits in sleep, or simple focal seizures
weird feelings in face and tongue
15% of all childhood epilepsies
doesn't require treatment often
focal sharp waves from Rolandic/centrotemporal area
remission in adolescence usually (majority)
Early-onset benign childhood occipital epilepsy (Panayiotopoulous): 1-14yrs old
- visual disturbance, eye deviation vomiting, autonomic features in younger
- headache and visual disturbance, distortion of images, hallucinations in older
-remission in childhood
Some may have learning difficulties
Juvenile myoclonic epilepsy: adolescence
- mostly myoclonic but can other types
- commonly after waking - 'throws drinks or cornflakes'
- learning unimpaired
- remission unlikely
- requires lifelong tx but usually can be well managed
- truly photosensitive
- EEG characteristic with fragments and irregular discharges, polyspike
Epileptic
Treating convulsive status epilepticus in children (defined as generalised >30m or repeated tonic-clonic over 30mins with no recovery. Start treating as if STATUS if fitting for >5 minutes to prevent status: Treating convulsive status epilepticusTime 0 mins (1st step)
- Seizure starts
- Check ABC, high flow O2 if available
- Check blood glucose
- Confirm clinically that it is an epileptic seizure
5 mins (2nd step)
- Midazolam 0.5 mg/kg buccally
or
- Lorazepam 0.1 mg/kg if intravenous access established
Midazolam may be given by parents, carers or ambulance crew in non-hospital setting
15 mins (3rd step)
- Lorazepam 0.1 mg/kg intravenously
This step should be in hospital
Call for senior help
Start to prepare phenytoin for 4th step
Re-confirm it is an epileptic seizure
25 mins (4th step)
- Phenytoin 20 mg/kg by intravenous infusion over 20 mins
or (if on regular phenytoin)
- Phenobarbital 20 mg/kg intravenously over 5 mins
Paraldehyde 0.8 ml/kg of mixture may be given after start of phenytoin infusion as directed by senior staff
Inform intensive care unit and/or senior anaesthetist45 mins (5th step)
- Rapid sequence induction of anaesthesia using thiopental sodium 4 mg/kg intravenously
- Transfer to paediatric intensive care unit
Anticonvulsants
First line for long term control:Sodium valproate is first line for the idiopathic childhood generalised epilepsy syndromes. Lamotrigine = 2nd line. Others = clobazam, topiramate, levetiracetam.
- except for ABSENCE epilepsy (ethosuximide)
- teratogenic (NTDs) during pregnancy; not for breastfeeding
- 2x as likely to produce seizure freedom than other drugs
- SEs include weight gain, hair loss. Deranged LFTs rarely
Carbamazepine is first line for focal epilepsies. Other options consider sodium valproate (but girls >9yo), lamotrigine - v effective but needs a slow titration, topiramate, levetiracetam.
- SEs include dizziness, headache, nausea, sedation, dry mouth.
Rash, neutropaenia, hyponatraemia, ataxia
- not for pregnancy or breastfeeding
- NOT for absence or myoclonic seizures as can make them worse
AED therapy can be discontinued after 2 years free of seizures (usually!)
Driving only after 1 year of seizure free for adolescents
SEs of AEDs:
Lamotrigine - rash
Ethosuximide (absence) - N+V
Topiramate (also for migraine) - drowsiness, withdrawal, weight LOSS
Gabapentin - insomnia
Levetiracetam - least SEs? Rarely sedation
-
Febrile seizures for comparison:
There is neither clinical nor laboratory evidence of an infective process directly involving the CNS
The temperature is 38 degrees Celsius or higher, in a child who has not had convulsions in the absence of fever
Onset is between 3 months and 6 years of age
Investigation:History - detailed witnessing of the episode.
- specific triggers?
- any impairments in child?
Examination - skin markers - neurocutaenous sydromes?
- neurological abnromalities, focal signs?
EEG always important to do - identify abnormal background
- unless seizure captured on EEG can only be supportive not diagnostic evidence
- asymmetry or slow = ?structural abnormality?
- hyperexcitability/sharp waves/spike-wave complexes
- imaging (MRI and CT) not required routinely only if suspecting structural problem. Image if there are focal signs or focal seizures, signs between seizures
- consider metabolic investigations if seizures coming with developmental regression or fits relating to feeding/fasting