Management of the Fitting Child

Dr Mergan Naidoo

Seizures
A seizure is a change in movement, attention or level of awareness that is sustained or repetitive and occurs as a result of abnormal neuronal discharges within the brain. When seizures are recurrent or typical of a specific syndrome, then the term epilepsy is used and specific management applies.

Epidemiology
Incidence of epilepsy: 30 50 /100 000 Prevalence of epilepsy: 0.5 0.8 % partial epilepsy 60% generalized epilepsy 25% absence epilepsy10%

Causes of seizures in children

Past perinatal conditions congenital infection hypoxic-ischaemic damage trauma cerebral haemorrhage or thrombosis cerebral malformation or degeneration

Poisoning
accidental ingestion of medicines medicine withdrawal in infancy environmental toxins

Infections
meningitis encephalitis brain abscess febrile convulsion (Commonest cause)

Metabolic conditions
hypoglycaemia hypocalcaemia hypomagnesaemia hyponatraemia hypernatraemia inborn errors of metabolism

Systemic disorders
vasculitis Hypertensive encephalopathy uraemia (renal failure) Hyperammonaemia (liver failure)

Primary Cerebral Causes

Trauma Haemorrhage Thrombosis Genetic/familial (syndromic) Tumour Idiopathic

Generalised seizures:
The epileptic focus arises centrally and spreads to the rest of the brain

Generalised seizures may be: tonic-clonic (grand-mal convulsion) absence clonic tonic myoclonic Generalised Tonic Clonic Seizures (GTCS) that continue for more than 30 minutes are called Convulsive Status Epilepticus

Partial seizures:
The epileptic activity arises from a particular focus within the brain.

Simple partial seizure: a focal seizure with retained consciousness. Complex partial seizure: a focal seizure with spread of the seizure to involve the whole cerebral cortex, resulting in an altered level of consciousness

DIAGNOSTIC CRITERIA
Clinical
History: Eye witness account, aura Perinatal history, developmental history, school record and family history Environment Examine to exclude obvious aetiology, but in particular look for occult causes: General: skin abnormalities, e.g. Sturge Weber and tuberous sclerosis CNS examination for loss of consciousness, localising signs, head growth, Developmental milestones and fundi CVS examination: blood pressure

Investigations
Always consider hypoglycaemia as a primary or aggravating cause of any seizure
Blood glucose thick/thin film electrolytes serology culture metabolic screen FBC toxicology urinalysis: blood and protein in renal hypertension, MCS for UTI Lumbar puncture: if meningitis is suspected and for first febrile generalised tonic clonic seizures in children < 2 years old Note: Lumbar puncture is contra indicated in the presence of the following: Increased intracranial pressure GCS < 12/15 (paediatric coma scale reduced by 3 points or more) Focal neurological signs/seizures. If the seizure has progressed to status

Other Investigations
CT/MRI scan: if persistently reduced coma score (GCS < 12/15) without known cause, raised intracranial pressure or focal intracranial pathology is suspected EEG: is only indicated for recurrent or syndromic seizures where diagnosis cannot be made on clinical grounds alone. The EEG is to be delayed for at least one week after the convulsive episode.

NON-DRUG TREATMENT
Ensure an open airway and administer oxygen, if available Position to prevent aspiration of vomitus, i.e. head up position Check glucose during the seizure and blood pressure after the seizure Obtain intravenous access if seizure duration > 5 minutes Keep child nil per os and intravenous fluid volumes at maintenance rates Control fever with tepid sponging Aetiology will determine further management

DRUG TREATMENT (Of a first time seizure)

For fever : Paracetamol, oral, 1015 mg/kg/dose 46 hourly as required Urgent drug treatment is only indicated if the seizure is generalised and lasts more than 5 minutes or is causing systemic compromise treat as for Status Epilepticus

EPILEPSY
A condition characterised by recurrent seizures associated with abnormal paroxysmal neuronal discharges

Seizures are managed according to type (i.e. generalised or partial) and also according to specific syndromes.

Epileptic syndromes:
Infantile spasms (Wests Syndrome)
An infantile onset encephalopathy with epileptic spasms associated with hypsarrhythmia on the EEG and developmental regression It is a neurological emergency diagnosis, treatment and referral must not be delayed. Early intervention reduces the subsequent neurodisability. Clinically, the child appears to stare, give a sudden flexion of the trunk and head, with the limbs either flung in or out but held in this tonic spasm for a few seconds Events occur in runs and are most common when the infant is going to sleep or rousing The episodes are distressing to the infant and he will often appear red in the face and may cry out Events are often confused with colic

Severe Myoclonic Epilepsy of Infancy (SMEI).

Onset in children under 1 year of age with recurrent clusters of febrile convulsions, severe neuroregression and other nonfebrile seizures by 23 years

Lennox-Gastaut syndrome (LGS)

Combinations of GTCS, atypical absences, myoclonic seizures, atonic drop attacks and occasionally complex partial seizures May occur spontaneously Onset between 23 years of age Behavioural problems and neuroregression occurs

Benign focal epilepsy of childhood

Sleep related events of hemifacial clonic spasm Inability to speak but retained awareness Onset at 610 years Usually resolves by late adolescence

Primary generalised absence seizure of childhood (petit mal) Short spells of motor arrest of maximum 15 seconds duration with little or no associated movements, no post-ictal effect Onset 46 years Generalised epilepsy with febrile seizures plus (GEFS+) Children with febrile convulsions which persist beyond 6 years Occasionally associated with afebrile convulsions These children have epilepsy triggered by fever and may warrant anticonvulsant intervention Often family history of febrile convulsions

DIAGNOSTIC CRITERIA
A child may be diagnosed: With a specific anatomical or systemic cause for the seizure type As having an epileptic syndrome, i.e. a specific seizure type associated with a characteristic EEG, natural history, response to therapy and prognosis With idiopathic epilepsy

Four common problems

1. The first seizure should treatment be started? risk of recurrence? how effective are AEDs? 2. Which AED should be used?

3. Treating refractory seizures

4. When to stop AEDs

NON-DRUG TREATMENT : ACUTE

Maintain an open airway Place patient on side at 2030 head up , admit to h igh or intensive care, if possible If unconscious, consider catheterisation. Monitor: heart rate, acidbase status, respiratory rate, blood gases, blood pressure, SaO2, electrolytes, neurological status, blood glucose, fluid balance anticonvulsant blood levels, serum osmolality Control fever with tepid sponging Administer oxygen 100 % by facemask, nasal cannula or head box to maintain SaO2 of 95% Cardiovascular and/or respiratory support if the patient is unable to maintain blood gases and blood pressure within the normal physiological range Ventilation to maintain PaCO2 in the low normal range, i.e. 4 4.5 kPa

LONG TERM
Minimise the impact of the epilepsy by obtaining complete seizure control to maximising childs full potential Educate the patient and caregiver about epilepsy and associated complications, i.e. learning difficulties and ADHD

DRUG TREATMENT
TREAT MENT
Generalised Tonic and/ or clonic Partial

SEIZURE TYPE
Infantile Spasms Absence Myoclonic

1st line

sodium carbamazepi ne valproate OR phenobarbital (< 6 months) carbamazepi ne sodium valproate

Refer

sodium valproate

refer all for specialist investigations

2nd line 3rd line

refer

refer for specialist decision on lamotrigine

refer for specialist decision on lamotrigine

Sodium valproate, oral, 2040 mg/kg/24 hours in 23 divided doses The slow release formulation enable school going children to take medication in a manner such that is does not sedate them with peaks and troughs and can be taken twice a day i.e. not at school. Monitor for hepatotoxicity in children under two years of age. Carbamazepine, oral, 1520 mg/kg/24 hours in 23 divided doses Initiate slowly over a period of 23 weeks. Exacerbates myoclonic seizures and absence seizures.

Lamotrigine, oral, 0.2 mg/kg/day Use as a third line agent, specialist initiated. Increase dose incrementing to 5 mg/kg/day slowly in conjunction with valproate. Lamotrigine is given as add-on therapy for many seizure types drug-resistant paediatric epileptic syndromes, such as LennoxGastaut syndrome. Phenobarbital, oral, 35 mg/kg/24 hours as single dose at night May be used in children under six months of age. Is not recommended as maintenance therapy for children older than 2 years due to undesirable side effects such as sedation, behaviour disturbances, hyperkinesia and dependence, except in situations where there is poor adherence to other drugs. Exacerbates absence seizures

Spectrum of Antiepileptic drugs

Generalised seizures
absence myoclonus tonic/atonic primary T/C

Partial seizures
simple partial complex partial 2dry T-C

ethosuximide

carbamazepine phenytoin oxcarbazepine vigabatrin gabapentin tiagabine

valproate lamotrigine topiramate levetiracetam phenobarbitone benzodiazepines

Carbamazepine life = 12 20 hrs Phenytoin life = 20 30 hrs Phenobarbitone life = 100 hrs Valproate life = 10 20 hrs

Drug level

Time

Principles of use of anticonvulsant drugs

1) Drugs differ mainly in pharmacokinetic properties, interactions,

adverse effects and cost 2) Choose a low starting dose and titrate slowly 3) Increase the dose until seizures controlled or side effects occur 4) If seizures not controlled, start another appropriate AED 5) Most drug interactions are based on induction of P450 system 6) Drug levels are for compliance and toxicity

Drug level Linear kinetics Zero kinetics

Dosage

New AEDs Gabapentin Lamotrigine Topiramate

SPS,CPS, GTC No hepatic metabolism Fatigue Indication for pain conditions Minimal cognitive impairment Rash Impaired memory, weight loss Word finding difficulty Rapid onset of action Minimal drug interactions May augment glaucoma Rare cause of renal stones Useful for migraine Dizziness, hyponatraemia No hepatic metabolism Rapid onset of action May benefit myoclonus

SPS,CPS, 1-2 GTC SPS, CPS, 1-2 GTC

Oxcarbazepine SPS, CPS, 1-2 GTC Levetiracetam

SPS, CPS, 1-2 GTC

The patient with refractory seizures

1) Wrong diagnosis 2) Poor compliance 3) Inappropriate drug 4) Psychogenic seizures 5) A refractory epileptic syndrome

REFERRAL
Suspected secondary cause Partial seizures for neuroimaging if facilities or expertise not available Generalised seizures other than typical febrile convulsions in children < 2 years Seizures that are not controlled within 2 months on one agent with minimal side effects Neuroregression Mixed seizure types within one patient. All myoclonic seizures and infantile spasms at presentation

FEBRILE SEIZURES
DESCRIPTION Seizures occurring in children between the ages of 3 months and 5 years associated with a rapid rise in temperature at the beginning of an extracranial illness. Febrile seizures can be simple or complex febrile seizures.

Simple febrile seizures

Are generalised tonic clonic seizures Are self limiting, usually less than 5 and always less than 15 minutes Cause no neurological deficit after the convulsion Have a good prognosis and very rarely develops into epilepsy Often consists of only one seizure which needs no specific treatment There is often a family history of febrile seizures

Complex febrile seizures

Last longer than 15 minutes Are recurrent within the same febrile illness Have a focal (partial) onset Have postictal, focal neurological abnormalities Risk factors for recurrent febrile seizures include: Seizure disorder in a first degree relative Onset before 12 months of age Complex initial seizures

DIAGNOSTIC CRITERIA
Clinical Exclude intracranial, extracranial and biochemical causes Signs of meningism are unreliable in children under 2 years If raised intracranial pressure or meningitis cannot be excluded then the diagnosis of febrile seizures cannot be made. Treat children empirically for meningitis.

Investigations A lumbar puncture is indicated in: Children under 2 years for exclusion of intracranial infection even when signs of meningism are absent All children who have no focus of infection, particularly those who have received antibiotics prior to the event In children older than 2 years, where a focus of extracranial infection is present and intra-cranial infection has been excluded clinically, no further investigation is required. All children with complex seizures and persistent lethargy should have a ct scan and then a lumbar puncture if raised intracranial pressure can be reliably excluded An EEG is of no value in simple febrile seizures

Non-drug treatment Control fever with tepid sponging Reassure parents and caregivers Educate parents and caregivers regarding the management of future episodes of fever Drug treatment For fever: administered by parents Paracetamol, oral, 1015 mg/kg/dose 46 hourly until fever subsides

Continuous prophylactic therapy

Routine daily prophylaxis is not recommended for patients with simple febrile seizures. For children with recurrent complex febrile seizures, prophylactic treatment can be considered, preferably in consultation with a paediatrician. Phenobarbital, oral, 5 mg/kg/day as a single dose or Sodium valproate, oral, 2040 mg/kg/24 hours in 3 divided doses

Referral Complex febrile seizures for confirmation of diagnosis Developmental delay/regression

Status Epilepticus
Diazepam 0.5mg/kg rectally
Still convulsing after 10 minutes

Lorazepam 0.1mg/kg IVI Still convulsing after 10 minutes Phenytoin 18mg/kg over 30 min in N/S Cardiac Monitoring Still convulsing at the end of phenytoin infusion Refer for ICU admission. Intubation with thiopental Sodium. Start infusion of midalolam 0.5-5ug/kg/min

References
Hospital Level Paediatrics STGs and EDL 2006 DOH Professor P.A. Bill Lecture notes EMU UKZN 2007 APLS