October 21, 2011

GOOD MORNING! WELCOME

APPLICANTS!

What to do?

FIRST NONFEBRILE SEIZURE

25,000 to 40,000 per year

Cannot be explained by an immediate, obvious provoking cause such as head trauma or intracranial infection

NONFEBRILE SEIZURE

HISTORY

AgeFamily HistoryDevelopmental StatusBehaviorHealth at seizure onset – febrile, ill, exposed to

illness, sleep deprivedPrecipitating event other than illness – trauma, toxins

ASSOCIATED FACTORS

AuraBehaviorPreictal symptomsVocalMotor

Head or eye turning, eye deviation, posturing, jerking, stiffening, automatisms

RespirationAutonomic

Pupillary dilation, drooling, incontinence, vomitingLoss of consciousness

SYMPTOMS DURING SEIZURE

AmnesiaConfusionLethargySleepinessHeadachesMuscle achesTransient focal weakness (Todd’s paresis)Nausea or vomiting

SYMPTOMS FOLLOWING SEIZURE

Breath-holding spellsSyncopeGERDpseudoseizures

IS IT REALLY A SEIZURE?

PHYSICAL

PHYSICAL EXAM

State of consciousness, language, social interactionGlobal developmentDysmorphic features, neurocutaneous skin findings,

organomegaly, limb asymmetryHead circumferenceNeuro exam

Cranial nerves Motor strength and tone Reflexes Gait Cerebellar and sensation tests

EVALUATION

LABORATORY STUDIES

Recommendations

Should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline status

Toxicology screening should be considered across the entire pediatric age range if there is any question of drug exposure or substance abuse

CBC, BMP, CALCIUM, TOX SCREEN?

Children under 6 months of age

Some studies show a 70% incidence of hyponatremia associated with seizures in this age group

EXCEPTION TO THE RULE

LUMBAR PUNCTURE

Recommendation

In the child with a first nonfebrile seizure, LP is of limited value and should be used primarily when there is concern about possible meningitis or encephalitis

LUMBAR PUNCTURE

EEG

Recommendation

The EEG is recommended as part of the neurodiagnostic workup of the child with an apparent first unprovoked seizure

EEG

Helps to determine seizure type, epilepsy syndrome, and risk for recurrence

Optimal timing is not clear An EEG done in the first 24 hours will most likely show

abnormalities, but can be due to postictal slowing

There is no evidence that the EEG must be done before discharge from the ED Can be arranged on an outpatient basis

EEG

NEUROIMAGING

Recommendations

If a study is obtained, MRI is the preferred modality

Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit or who has not returned to baseline within several hours after the seizure

Nonurgent neuroimaging with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neuro exam, a focal seizure, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under 1 year of age

NEUROIMAGING

TREATMENT

Discuss all strategies with patient/parents Antiepileptic drugs Special diets (ketogenic diet) Surgery Vagus nerve stimulation

Most neurologists do not recommend AEDs after a fi rst seizure because only 30% have a second seizure

After 2 seizures, the risk of having a third one increases to about 75% without treatment AED is usually started after 2 seizures

1/3 of patients are refractory to medication

TO TREAT OR NOT TO TREAT?

SEIZURE PRECAUTIONS

PRECAUTIONS

Patient/parents should be informed about possible precipitating factors:

Sleep deprivation Hyperventilation Alcohol abuse Recreational drugs Photic light stimulation

Yes! They can participate in sports

Basic safety precautions No swimming or bathing alone

CAN THEY PLAY SPORTS?

Yes! They can drive

Each state has diff erent laws

Most suggest being seizure free for 6-months

CAN THEY DRIVE?

Noon Conference

OUTER EAR DISEASE, DR. SIMON