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management
of
Neonatal Seizures
Moderator : Dr. Dilip Singh
Presented by : Dr. Abdul Quddoos
Neonatal seizures
Definition : A seizure is defined clinically as a
Diagnostic dilemmas:
Clinical Vs EEG criteria
Neonatal seizures are generally brief and subtle
clinical
events
with
coincident
Clonic Seizures
Tonic Seizures
Electrographic Seizures
Electrographic
status
epilepticus
underdiagnosed.
Without
would
be
EEG
confirmation,
the
underdiagnosis of status epilepticus would
contribute to brain injury.
expressions
of
neonatal
seizures
after
antiepileptic medication administration also
contributes to the underestimation of the true
seizure duration and frequency of status
epilepticus .
Electroclinical dissociation
There is asynchrony between the clinical and
affected limb
cyanosis).
Autonomic phenomena.
Infant was conscious or sleeping at the
occurred.
Antenatal history
Intrauterine infection
Maternal diabetes
Narcotic addiction
A history of sudden increase in fetal
Perinatal history
of neonatal seizures
Fetal distress
Decreased fetal movements
Instrumental delivery
Need for resuscitation in the labor room
Apgar scores
Abnormal cord pH (<7) and base deficit
(>10 mEq/L)
Use of a Pudendal block for mid-cavity
forceps may be associated with accidental
injection of the local anesthetic into the
Feeding history
Appearance of clinical features including
Family history
Consanguinity in parents
Seizures or mental retardation
Early fetal/neonatal deaths -inborn errors
of metabolism.
History of seizures in either parent or
sib(s) in the neonatal period may suggest
benign familial neonatal convulsions
(BFNC).
General examination
Systemic examination
Presence of hepatosplenomegaly or an
Investigations
Essential laboratory investigations include:
Blood glucose
Serum calcium, ionized calcium if possible
Serum magnesium
Lactate
Serum sodium
Serum urea and creatinine
Lumbar puncture
Blood culture
Cranial ultrasound scan.
EEG
Additional investigations
Neuroimaging (CT, MRI)
Screen for congenital infections (TORCH)
Inborn errors of metabolism (IEM).(S.
Imaging
Neurosonography
of
intraventricular
parenchymal hemorrhage
Unable
to detect
hemorrhage.
SAH
and
and
subdural
CT scan
Cerebral dysgenesis
Lissencephaly
Neuronal migration disorders.
Management
Initial medical management:
The first step in successful management of seizures is
to nurse the baby in thermoneutral environment and
to ensure airway, breathing, and circulation (TABC).
Oxygen should be started if needed, IV access should
be secured, and blood should be collected for glucose
and other investigations.
A brief relevant history should be obtained and quick
clinical examination should be performed. All this
should not require more than 2-5 minutes.
Corrective Therapies
Rapid infusion of glucose or other supplemental
Hypocalcemia-induced
seizures should be
treated with an intravenous infusion of 200
mg/kg of calcium gluconate.
This dosage should be repeated every 5 to 6
hours over the first 24 hours.
Serum magnesium concentrations also should
be measured, because hypomagnesemia may
accompany hypocalcemia; 0.2 mg/kg of
magnesium sulfate should be given by
intramuscular injection (Scher, 2001b).
Antiepileptic medications
Who should be treated
When to begin treatment
Which drug to use
How long.
Anti-epileptic
If
Drug Therapy
Phenobarbital remains the current first-line
treatment of neonatal seizures worldwide, in
spite of evidence that it is effective in only about
a third of cases and there is concern about the
effects of this drug on brain development,
including apoptosis (Painter et al.1999; Bittigau et al.
2002; Boylan et al. 2004; Kaindl et al. 2006; Ikonomidou
and Turski 2010).
Recently
In
recent
combination of phenobarbital and phenytointhey are usually suffering from severe hypoxic
ischaemic encephalopathy and their prognosis
is poor.
The choice of third-line anticonvulsant varies,
to 0.1 mglkg.
Diazepam dose is 0.3 mg/kg IV @ infusion
is
a
short-acting
benzodiazepine that has been used as a
continuous IV infusion (0.1-0.4 mg/kg/hour)
after an initial loading dose (0.15 mglkg).
Maintenance anticonvulsants
Phenobarbital in a dose of 5 mg/kg/day is the usual
Prognosis
The prognosis depends largely on the cause
of the seizures
Worse for those with hypoxicischaemic
encephalopathy, meningitis and cerebral
malformations
Better for hypocalcaemia, benign familial
neonatal seizures, subarachnoid haemorrhage
or stroke (Tekgul et al. 2006)
Mortality and morbidity are greater in preterm
babies (Scher et al. 1993a; van Zeben et al.1990)
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