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M a x A n g e l o G . T e r r e n a l
Seizures andStatus Epilepticus
in Children
What is a SEIZURE?
paroxysmal involuntary motor activity
and/or
changes in behavior
caused by synchronous firing of a group of neurons in the brain
glutamate vs
GABA
excitatory
inhibitory
electroencephalogram
Children less than 5 years old
Children less than 5 years old
excitatory > inhibitory
excitatory > inhibitory
Children less than 5 years oldPeriod of Vulnerability
cognitive impairment and
behavioral abnormalities
CNS disease or anticonvulsants?
A single prolonged
seizure has been
shown to damage the brain
30
temporal lobes
andhippocampus
EPIDEMIOLOGY
seizure disorders
are the most common neurologic
disorders of childhood
4 to 10% suffer at least one seizure in
the first 16 years
30%who have a first afebrile
seizure develop epilepsy
3% cumulative lifetime incidence
of epilepsy
FEBRILE SEIZURES
30%recur after first episode
FEBRILE SEIZURES
50%recur after 2 or more
of infants <1 y/o at onset
FEBRILE SEIZURES
2-7%proceed to epilepsy
CLINICAL
PRESENTATION
DIAGNOSIS
seizure or not?
syncopePreceded by • dizziness• weakness• tunnel vision• pallor• diaphoresis
Associated with • brief loss of
consciousness
• quick recovery with no postictal state
seizurescyanosis
tongue bitingrhythmic motor activity
incontinenceslow recovery and postictal
state
vs
convulsive generalizedboth hemispheres
motor activity on both sides
nonconvulsivegeneralized
both hemispheresno motor activity
recognizable by EEG
other generalized
absenceatonicmyoclonic
other generalized
absenceatonicmyoclonic
other generalized
absenceatonicmyoclonic
other generalized
absenceatonicmyoclonic
simple febrile seizures
or
complex febrile seizures
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
febrile seizuresanticonvulsant therapy is not
recommended for simple febrile
seizures
STATUS EPILEPTICUS
prolonged or recurrent
>5 minutes without regaining
consciousness
REFRACTORY STATUS EPILEPTICUS
uncontrolled with 2 or more standard
doses of treatment
MANAGEMENT
most seizures stop within 5
minutes and do not require medical
treatment
Status Epilepticusseizure > 5 minutes
or
multiple seizures over a
period of > 5 minutes
PREHOSPITAL
benzodiazepine
Oxygen support
Oxygen support
IV access
Oxygen support
IV access
• Rapid bedside electrolyte level
• Complete blood count
• Full chemistry panel
• Hepatic and renal studies
• Anticonvulsant levels
intubate = clinicalapnea and persistent hypoxia
blood gas concentration
paralytic
blood gas concentration
paralytic
metabolic and respiratory Acidosis
obscure assessment
continuous EEG monitoring
benzodiazepinesFIRST LINE
FIRST LINE
benzodiazepinesbind to GABA receptors
benzodiazepinesFIRST LINE
Diazepam
Lorazepam
Midazolam
Lorazepam
benzodiazepinesFIRST LINE
Diazepam
Lorazepam
Midazolam
Lorazepamfewer side effectslonger duration
Initial benzodiazepine treatment
should be limited to 2 doses
FIRST LINE
SECOND LINEfosphenytoin
or phenobarbital
SECOND LINEfosphenytoin
phenytoinstabilizing sodium channels
SECOND LINEphenobarbital
bind to GABA receptors
SECOND LINEfosphenytoin >
phenytoin
SECOND LINEfosphenytoin >
phenytoinprecipitate in an IV linehypotension
cardiac arrhythmias
SECOND LINEfosphenytoin >
phenytoinprecipitate in an IV linehypotension
cardiac arrhythmiasmust be given slowly
SECOND LINEfosphenytoin >
phenobarb
SECOND LINEfosphenytoin <
phenobarballergies to phenytoin
with a febrile illness
<2 years of age
THIRD LINEvalproic acidlevetiracetam
low electrolyte levelshypoglycemiahyponatremiahypocalcemia
hypomagnesemia
hypoglycemiaGlucose < 50 mg/dl
2 ml/kg 25% dextrose in water
hyponatremiaSodium < 135 mEq/L
Seizures at < 120 mEq/dl3% NaCl for active seizures
hypocalcemia10% calcium gluconate
0.3 mL/kg
slowly over 5 to 10 minutes
hypomagnesemiaMg < 1.5 mEq/L
50 mg/kg IV infused over 20 minutes
Philippine CPG
first febrile seizure
lumbar puncture should be
performed in all children
below 18 months with a first
simple febrile seizure
Philippine CPG
children 18 months and older,
lumbar puncture should be
performed in the presence of clinical signs
Philippine CPG
meningeal signsand
sensorial changes
Philippine CPG
neuroimaging studies should not be routinely
performed
Philippine CPG
Antipyretic drugs are used to
lower fever and should not be relied upon to prevent the
recurrence of febrile seizures
Philippine CPG
For a first simple febrile seizure
the use of intermittent or continuous
(phenobarbital or diazepam)
is not recommended for
the prevention of recurrent febrile seizures.
Philippine CPG
Electroencephalogram
should not be routinely
requested
Philippine CPG
Thank you
