Children and infant with seizure

CHILDREN AND INFANT WITH SEIZURE

I.      INTRODUCTION

Seizures are a common occurrence in children. About 8% will have at least one seizure by 15

years of age. Many underlying conditions and neurological challenges may provoke seizures. In over 50% of children seizures are isolated events associated with a high fever or minor head injury in young children. Most seizures in children are brief, terminate spontaneously and do not need any treatment.

Seizures that persist beyond five minutes may not stop spontaneously, so it is usual practice to institute anti-convulsive treatment.

II.      DEFINITION

A seizure may be defined as a sudden attack of altered behavior, consciousness, sensation or

function produced by a transient disruption of brain function.

Generalized convulsion (tonic-clonic) status epilepticus is defined as a generalized convulsion lasting 30 minutes or longer or when successive convulsions occur frequently over a

30 minute period and the patient does not recover consciousness between them.

III.      EPIDEMIOLOGY

Of all children, 3 to 5 percent will have a single febrile seizure in the first five years of life; 30

percent will have additional febrile seizures, and 3 to 6 percent of those with febrile seizures will develop afebrile seizures or epilepsy.

IV.      ETIOLOGY

1-  Febrile convulsion (6 months to less than 6 years)

•     Febrile convulsions are common in children 6 months to less than 6 years old.

•     The convulsion is usually short and generalized. The child may sleep following the convulsion, but can be aroused and there are no localized neurological signs.

The generally accepted criteria for febrile seizures include:

·       A convulsion associated with an elevated temperature greater than 38°C per axilla

·       A child younger than six years of age

·       No central nervous system infection or inflammation

·       No acute systemic metabolic abnormality that may produce convulsions

·       No history of previous afebrile seizures

2-  Convulsion due to infectious causes (other than febrile convulsion)

-     Severe malaria

-     Meningitis (including tuberculosis)

-     Encephalitis

3-  Afebrile convulsion

-     Hypoglycemia convulsion may occur in malnutrition, malaria and other severe

infection. Always confirm the diagnosis by using a gluocometer or taking venous blood.

-     Hyponatraemic convulsion

-     Hypocalcaemia convulsion may occur with severe malnutrition including Rickets. It

can occur also after repeated blood transfusion.

-     Convulsion due to intoxication or poisoning (see Intoxication CPG)

-     Convulsion due to epilepsy (see Epilepsy CPG)

-     Head trauma including child abuse

V.      APPROACH TO DIAGNOSIS History:

·    Gestation, birth, general health, growth and development

·    Current medication; allergies

·    Previous history of convulsion

·    Precipitating factors:

o Fever

o Preceding illness

o Sleep deprivation

o Recent head trauma

o Ingestion/poisoning

o Change in antiepileptic medication

Physical examination:

·    Vital signs: temperature, respiratory rate, heart rate, blood pressure

·    Complete Neurological examination: pupillary asymmetry, altered mental status, signs of meningism, fixed eye deviation, focal motor weakness

·    Signs of head trauma or child abuse: retimal hemorrhages, evidence of increase intracranial pressure

·    Head circumference: microcephaly or hydrocephalus

·    Complete general examination looking for infectious causes and other diseases

·    Skin examination: café au lait spots, facial hemangioma, purpura

·    Convulsions: focal or generalized

Investigations

·    bedside glucose

·    malaria smear (if in malaria area)

·    FBC

·    Where possible

o Electrolytes

o sepsis screening (e.g. blood culture, CSF, urine etc)

o calcium

VI.      TREATMENT

The priorities are:

1.   Initial resuscitation

2.   Stop convulsion

3.   Find and treat the cause of convulsion

1    Initial resuscitation:

The first step in the management of the patient who is having a seizure is to assess

o Airway = A o Breathing = B o Circulation = C   Airway:

and support airway, breathing and circulation. This will ensure that the seizure does not compromise supply of oxygenated blood to the brain and is not secondary to hypoxia and/or ischemia.

·    Open and maintain airway with simple maneuver (see basic life support CPG)

·    Secretion clearance with gentle suction

·    Put the child in recovery position (left lateral decubitus) to minimize the risk of aspiration once the child is breathing satisfactorily.

Breathing:

·    High flow oxygen via face mask with reservoir as soon as the airway is opened adequately

·    Support respiration with bag-valve mask ventilation and consider intubation if the child is hypoventilating.

Circulation

·    Gain iv or intraosseous access

·    Treat hypoglycemia (glycemia < 3mmol/l) with D10% 2ml/kg bolus and D10%1/2NSS 5ml/kg/h infusion (without follow on infusion there is a risk of rebound hypoglycemia)

·    Give NSS 20 ml/kg bolus to any patient with signs of shock (except cardiogenic shock, DKA, trauma and severe malnutrition – 10 ml/kg NSS bolus).(Refer to shock CPG)

2    Stop convulsion:

Start anticonvulsant medication (midazolam 0.2mg/kg IM or diazepam 0.25mg/kg IV or 0.5

mg/kg PR) if the convulsion lasts more than 5 minutes. Usually if the convulsion started pre hospital, then the duration might already be longer than 5 minutes before the arrival of the patient. In this case, start anticonvulsant medication immediately IM (midazolam) or diazepam IV or rectally if cannot access IV immediately

Repeat the dose if the seizure continues.  If after 2 doses the child is still seizing, treat with Phenytoin 20mg/kg IV over 20 minutes (max 1g) or Phenobarbital 15-20mg/kg IV over 20 minutes or via NGT (max 1g).

Monitor respiratory rate and have resuscitation facilities available including endotracheal tube as all these drugs cause respiratory depression.

(see the algorithm on management of convulsion below).

3    Find and treat the cause:

Once the convulsion has stopped, the effort of management depends on finding and treating

the causes of convulsion. If the patient is diagnosed as having a febrile convulsion, then the attempt to find the cause of fever should be made.

·    Give antibiotic (Ceftriaxone if > 2 months or Ampicillin/Gentamycin for infant < 2 months (see meningitis CPG)) to any patients thought to have infection leading to convulsion are likely.

·    Treat hyponatraemia (if presenting with seizure) with IV 3% NaCl  4ml/kg over 15 minutes

·    Treat confirmed hypocalcemia with 10% Calcium gluconate 0.5ml/kg, maximum

10ml over 15 minutes

Specialist consultation or transfer should be made in:

-     Children with compromise of vital functions

-     Prolonged seizures lasting more than 30 minutes

-     Seizure continuing after two doses of a benzodiazepam

-     Suspected serious underlying cause of seizures e.g meningitis, encephalitis, metabolic abnormality and head injury.

-     unable to determine the cause e.g. lack laboratory support to help with diagnosis (no blood gases, cannot check sodium, calcium level etc)

4    Monitoring

Reassess ABC

The vital signs should be reassessed frequently in addition to continuous monitoring with

ECG and oximetry:

-     After each dose of anticonvulsant medication

-     Continuous monitoring while the seizure continues

-     Every 15 minutes for at least an hour after a seizure until level of consciousness returns to normal.

VII.      COMPLICATIONS

There are many complications including:

a.   obstruction of the airway and hypoxia b.   aspiration pneumonia

c.   respiratory depression.

VIII.      EDUCATION

·    If the child has had a febrile convulsion, inform the parent convulsion can recur when the child is less than 6 years old.

·    When fever, reduce temperature by bath sponging

·    give paracetamol to reduce the fever

·    Bring the child immediately to health care facility.

·    If the child is experiencing of tonic-clonic seizure:

o Remain calm

o Roll on to their side immediately if they vomit

o Protect the child from harm

REFERENCES

1.   Samuels, M., Wieteska, S. Advanced Paediatric Life Support: The Practical Approach, Fifth Edition June

2011

2.    NSW Health: Infants and children: Acute Management of Seizures second edition 2009 sourced at http://www0.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_065.pdf

3.   Schwartz, M.W. 5-Minute Pediatric Consult 6th edtion June 2012

4.   Wilfong, A. Clinical features and complications of status epilepticus in children. Last updated

Jan 2012. Available from http://www.uptodate.com/contents/management-of-status-epilepticus-in- children?source=search_result&search=status+epilepticus&selectedTitle=3~150

5.   Wilfong, A. Management of status epilepticus in children. Last updated Jan 2012. Available

from

http://www.uptodate.com/contents/clinical-features-and-complications-of-status-epilepticus-in- children?source=search_result&search=status+epilepticus&selectedTitle=2~150

Thanks