Childhood Seizures tonic

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Childhood Seizures tonic Powered By Docstoc
					General Pediatrics, The University of Chicago
David Ogren MSIII 03/18/2002
Yingshan Shi, MD (773) 702-2600 2008

                                        Childhood Seizures
                                          Presentation                         EEG findings                       Treatment
Partial Seizures
                              Unusual motor activity (face, neck,      Spikes and or sharp waves       Carbamazepine is 1st line
                                extremity involvement)                  either unilaterally or           choice
       Simple Partial         Consciousness maintained                 bilaterally
                              May have preceding “aura” of strange
                              Seizures for 10-20 sec
                              May begin as simple partial and then     Anterior temporal lobe sharp    Carbamazepine is 1st line
      Complex Partial          progress                                 waves and focal spikes           choice
                              Impaired consciousness but not loss                                      Neurontin is used for
                               (can’t describe episode)                 Can see multifocal findings      refractory seizures
                              May have preceding “aura” of             occasionally                     (especially >12 yo)
                              Can see “automatisms” after seizure
                               (lip smacking, chewing, swallowing,
                               salivation,  responsiveness)
                              Seizures for 1-2 min
                              Subacute inflammatory condition          Diffuse paroxysmal activity    Unproven therapy
  Rasmussen Encephalitis      Usually see preceding febrile illness    with a slow background
                              Focal seizures that may be frequent to
                              Usually seen before 10 yo
                              Often self-limited and lead to
                               significant focal neurologic deficits
                               (hemiplegia, aphasia, hemianopsia)
Generalized Seizures
                              Sudden cessation of motor                3/second spike and             Valproic acid or Ethosuxamide
         Absence               activity/speech with blank expression    generalized wave discharge
                               and flickering eyelids
                              Usually after 5 yo
                              Usually lasts < 30 sec
                              No aura or post-ictal state
                              Automatisms frequently accompany
                              Quite common and often follow                                             Place head to the side and
      Tonic - Clonic           simple seizure                                                             extend the jaw/neck
                              May have preceding aura                                                   Do not forcibly open the
                              Loss of consciousness and may make                                         mouth
                               a cry with onset of seizure                                               Carbamazepine/valproic
                              Eyes roll back and whole body has                                          acid/phenobarbitol are 1st
                               rhythmic tonic contractions followed                                       line options
                               by relaxation                                                             Neurontin is 2nd line choice
                              Cyanosis occurs                                                           Precipitating factors include
                              Commonly lose sphincter control                                            infectious fever, fatigue,
                              Usually last several min                                                   stress, psychotropic drugs,
                              Post-ictally can see flaccid comatose                                      methylphenidate
                               patient with vomiting and headache
                              Repetitive seizures of brief and          From normal to fast spike      Valproic acid is 1st line
    Myoclonic Seizures         symmetric muscular contractions with       wave complexes of  2.5         agent
                               loss of body tone and                      Hz with normal                 Clonazepam is back up
                               falling/slumping                           background
                              Broad spectrum of presentations and       Can see interictal slow
                               outcomes in the pediatric population       spike waves
                                                                         Can see irregular 4-6/sec
                                                                          spike and wave pattern

General Pediatrics, The University of Chicago
David Ogren MSIII 03/18/2002
Yingshan Shi, MD (773) 702-2600 2008

                                        Childhood Seizures
                                          Presentation                         EEG findings                     Treatment
   Generalized Seizures
    Status Epilepticus        Continuous convulsions >30 min or        EEG changes associated          Assess respiratory and
                               serial convulsions                       with underlying seizure          circulatory systems
                              Loss of consciousness occurs             subcategory                     IV anticonvulsant, starting
                              Can be any of the generalized seizure                                     with diazepam or
                               types (absence, tonic-clonic, partial)                                    lorazepam, followed by
                              Those with underlying CNS disorder                                        phenytoin
                               have higher morbidity and mortality                                      Refractory status can be
                               rates                                                                     treated with paraldehyde,
                                                                                                         diazepam drip, lidocaine or
                                                                                                         general anesthesia
                                                                                                        Once stabilized, find and
                                                                                                         treat any underlying
                                                                                                         causative agent (infection,
                                                                                                         metabolic, anoxia,
                                                                                                         encephalopathy, electrolyte
Other seizures
                              Most common childhood seizure with       Usually normal EEG              Search for the source of the
     Febrile Seizures          excellent prognosis                                                       fever
                              Usually seen between 9 months and 5                                      Control fever with
                               years old                                                                 antipyretics, especially at
                              Strong family historyof febrile                                           onset
                               seizures                                                                 If febrile seizures are
                              Associated with rapidly rising temp.                                      recurrent, oral diazepam
                               and usually >39C                                                         prophylaxis at onset of new
                              Usually generalized, tonic-clonic                                         fever
                              Usually last <5 min (but up to 10 min
                              Usually begin between 4-8 months         Hypsarrythmia which is         ACTH is 1st line
     Infantile Spasms         Brief symmetric contractions of neck,    chaotic pattern of high        Prednisone is backup
                               trunk and extremities                    voltage, bilaterally
                              Clusters usually last minutes            asynchronous, slow-wave
                              Can be either flexor, extensor or        activity
                               mixed spasms
                              Often occur with drowsiness or upon
                              More common in boys                       Bitemporal high               Valproic acid is 1st line
Landau-Kleffner Syndrome      Usually occur near 5 yo                    amplitude spike and           Try oral prednisone if
                              Loss of language skills in previously      wave patterns most             symptoms persist through
                               normal child                               common                         valproic
                              Hearing is normal                         Can see multifocal or         Speech therapy for several
                              Most have significant speech function      generalized patterns           years to improve language
                               abnormality in adulthood                  EEG changes seen more          function
                                                                          easily during non-REM
                              Could be either focal rhythmic            EEG changes associated        Usually caused by hypoxic-
    Neonatal Seizures          twitching of facial/extremity muscle       with specific seizure          ischemic encephalopathy
                               groups or multifocal with several          subcategory if one exists     Also metabolic, infectious
                               muscle groups involved                                                    (TORCHES), traumatic,
                              Could be tonic, myoclonic or subtle                                       structural or embolic causes
                               seizures (automatisms)                                                   Anticonvulsants for
                              Can see  BP and tachypnea                                                hypoxic-ischemic enceph.,
                              Prognosis varies depending on                                             acute cranial bleed
                               underlying etiology

General Pediatrics, The University of Chicago
David Ogren MSIII 03/18/2002
Yingshan Shi, MD (773) 702-2600 2008

                                         Childhood Seizures
Phenobarbital        Status                      Inhibits nerve growth factor may affect
                                                 developing brain
                                                 >Age 2 60% with irritability, aggression,
                                                 insomnia, agitation and attention and
                                                 concentration problems
Phenytoin            Status                      Cerebellar atrophy, facial hirsutism,
Dilantin                                         coarsening of facial features, serious skin
                                                 Relatively contraindicated for long term use
                                                 in young children
Carbamazepine        Partial                     Aggravate primary feneralized epileptic
Tegretol                                         syndromes
Tegretol XR                                      An enzyme inducing AED
                                                 Worry about osteoporosis
Valproate            Partial and generalized     1/500 risk of hepatotoxicity in children<2y
(Depalote)                                       who are on other AEDs and have other neuro
                                                 Risk of PCOS, weight gain
                                                 Tremor, alopecia, thrombocytopenia,
Gabapentin           Partial                     Agitation, irritability, and psychosis in
(Neurontin)          Not as effective as other   children with encephalopathies
Lamotrigine          Partial and feneralized     Allergic rash
(Lamictal)                                       No known cognitive side effects
Topiramate           >=2yo Board spectrum        Somnolence, cognitive impairment, word
(Topamax)            May be effective for        finding difficulties, weak carbonic anhydrase
                     infantile spasms with       inhibition --kidney stones
                     high doses


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