Julie Jaffray, MDEmily Pollakowski, MD

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

Febrile Partial

◦ Simple partial◦ Complex partial

Generalized◦ Absence◦ Myoclonic (muscle twitching)◦ Clonic (rhythmic shaking)◦ Tonic (rigid contracture)◦ Atonic◦ Tonic-clonic

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

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

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

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)

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

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

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%

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

Intracranial infection (meningitis, encephalitis)

Intracranial tumor (benign or malignant) Injury causing intracranial hemorrhage Metabolic disturbances (hypoglycemia)

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

Before anything else…A B C! Airway Breathing Circulation Stabilize patient Establish access and obtain labs

Airway

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

Breathing

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

Circulation

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

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

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

Important to monitor closely during administration of above medications

Vitals (RR, HR, BP) Level of consciousness

Diazepam-Respiratory depression-Hypotension

Phenobarbital-Respiratory depression-Hypotension

Phenytoin-Hypotension-Arrythmias

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

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