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Managing Your Child's Seizures

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Managing Your Child's Seizures Powered By Docstoc
					Care Of The Student With
   Seizures In School
         Mary Herndon, RN
          Hema Patel, MD
Pediatric Neurology, Riley Hospital
       September 30, 2008
Objectives
   Understand basic anatomy of the nervous
    system
   Identify common causes of seizures
   Evaluation and Investigations
   Describe different types of seizures
   Treatment options
   Seizure First-Aid
   Work with your doctor to manage your child’s
    seizures
       Basic Anatomy of the Nervous
                  System

   Brain - housed in skull
   Spinal Cord - supplies nerves to trunk
    and extremities
Central Nervous System
        Anatomy
                    Cerebrum
   Controls conscious mental process
   Divided in two halves: Right and Left
   Each half has four lobes (sections)
       Frontal
       Parietal
       Occipital
       Temporal
   Neurons in the cortex of cerebrum are tiny nerve
    cells that produce seizures
           Definition of Seizures
   A seizure is a sudden, unpredictable
    burst of excessive electrical activity in
    the brain
   Causes a change in behavior,
    consciousness, movement, perception
    or sensation
            Other terminology
   Seizures are also referred by other
    names such as:
           Fits
           Convulsions
           Spells
           Attacks
           Definition of Epilepsy
   Seizures which occur repeatedly over
    time or are recurrent or chronic
   In the US, about 5% of children and
    adolescents will have a seizure by age
    20
   Active cases of epilepsy:
    USA 6.8 patients per 1000 = <1%
    Causes - seizure can be a
    symptom of a medical problem
   Infection/Fever            Toxicity
   Trauma                     Hereditary Diseases:
   Brain Lesions:              Neurofibromatosis
    Tumors                      Tuberous Sclerosis
    Brain Malformations         Mitochondrial
   Metabolic Problems:        Family Tendencies
    Diabetes                   Idiopathic
    Nutritional imbalance        (no cause found)
          Diagnosis of Seizures

   Description of event
   Patient and family medical history
   Routine EEG (electroencephalogram) records
    electrical activity of brain
   Video EEG Monitoring - EEG plus video-tapes of
    patient during EEG
   MRI or CT (CAT Scan) - shows structure of the brain
   Blood work
   Lumbar puncture
   Urinalysis, Urine genetic screen
EEG
Absence Seizures
Head MRI
    Seizure Classification
   Why do we classify seizures?
       Identify seizure type
       Predict seizure prognosis/course
       Decide treatment
       Identify first aid strategies
       Anticipate life changing concerns
    Seizure Classification
   Generalized - the whole brain cortex
    has abnormal electrical activity
   Partial - abnormal activity in a specific
    part of the brain; may spread to whole
    brain
        Generalized Seizures
   Tonic-Clonic: (Grand Mal)
       No warning
       Loss of consciousness
       Body stiffens then jerks or shakes
        (convulses) rhythmically
       Color change – dusky or pale
       Incontinent (loss of urine)
       Oral secretions (vomiting, drooling)
       Postictal confusion and sleep
Generalized tonic-clonic seizure
         Generalized Seizures

Absence Seizures (Petit Mal)
   Very brief loss of consciousness, lasting
    seconds
   Staring, sometimes with eye fluttering
   Triggered by hyperventilation (rapid
    breathing)
   Happens many times a day
   Can affect learning
   Mistaken for daydreaming, ADHD
Absence seizure
          Generalized Seizures

Myoclonic Seizures
   Brief jerks of one or more parts of the
    body
   May be in clusters (one after another)
   Do not lose consciousness
Myoclonic seizures
        Generalized Seizures
Atonic Seizures (Drop seizures)
   Sudden loss of muscle tone
   Quick return to normal behavior
    (baseline)
   Often mistaken for abuse because of
    injuries
Atonic seizure
              Partial Seizures
 May have aura (warning, feeling,
  premonition)
 Focal - Jerking of specific body part

 Postictal confusion or drowsiness

Simple – without a change in consciousness
          motor or sensory symptoms
Complex – with change of consciousness
          Staring, automatisms (lip smacking,
    picking movements, wandering)
Complex partial seizure




                  Epilepsy Foundation of America
Problems Mistaken for Seizures
   Breath holding
   Syncope (fainting)
   Night Terrors/Sleep disorders
   Childhood Migraines
   Rage attacks
   Pseudoseizures
     Status Epilepticus
   Life threatening
   One or more seizures lasting greater
    than 30 minutes (However, a single
    prolonged seizure of >5-10 minutes is
    concerning)
       Emergency medical attention needed
       Call 911, go to Emergency Room
       Diastat (Rectal Valium/Diazepam) often
        ordered to be given
       IV medicines given in Emergency Room
    Seizure Management
There is no cure for epilepsy but
most (80%) can be managed with
medicine, a healthy life style and
an accepting attitude
    Risk Factors for Seizures
   Inadequate or improper anticonvulsant
    medication
   Trauma
   Illness/Fever
   Lack of Sleep
   Fatigue/Stress
        Risk Factors for Seizures
   Poor general health care or nutrition
   Photosensitivity –
    Flashing lights, computers/games (nintendo
      epilepsy)
   Hyperventilation
   Medicine, drug or alcohol ingestion or
    withdrawal
   Menses
    Effect of Medicine
   Changes the chemistry in the brain
   Normalizes electrical activity – stops or
    slows the spread of the abnormal
    electrical impulses
   Increases the seizure threshold
    Goal of Medicine Therapy
   THE LEAST NUMBER OF DRUGS
   AT THE LOWEST THERAPEUTIC DOSE
    to control seizures
   WITH MINIMUM SIDE EFFECTS
    Choice of Medicine
   By seizure type:
       Some medicines best for certain types of seizures
       Some medicines can make certain types of
        seizures worse
   Sex, age, child bearing risk
   Financial factors
   Ease of use (Given twice a day versus three
    times a day)
    Starting Medicine in Children
   Dose is decided by child’s body weight
    (mg/kg) and is different for every
    medicine
   Increased to therapeutic range or level
    of medicine in blood
   Takes time after an increase of dose,
    for effect to be seen (to reach a steady
    state)
       Seizure Medicines
Type     Absence    Partial     Tonic-Clonic   Myoclonic

         Zarontin   Tegretol    Depakote       Depakote
         Depakote   Trileptal   Lamictal       Keppra
         Lamictal   Topamax     Topamax        Zonegran
         Zonegran   Keppra      Phenobarb
         Keppra     Phenobarb Dilantin
         Klonopin   Dilantin    Keppra
    Blood Monitoring:
 Drug levels in the blood help decide
  dose of medicine
 Shows toxicity or compliance

 Shows side effects – liver toxicity,
  decreased blood cell production, kidney
  stones, pancreatitis
Usually blood is drawn before AM dose
Medicine Side Effects - Call
doctor
   Allergic reaction (rash) –
   Sleepiness – less active, lethargy
   Dizziness, poor coordination
   Blurred Vision
   Behavior or cognitive changes
   Interference with other medicines
    (blood thinners, birth control)
   Birth Defects
   GI disturbance        (stomach upset, nausea, vomiting)
Important Things to Remember
   Stopping seizure medicine quickly can
    cause serious seizures
   Plan ahead for refills
   Missing doses drops the blood level
    which can cause seizures
       Illness (unable to take, vomiting)
       Non compliance
Other Treatments
These are only used for patients with
  refractory seizures
Refractory means the seizures are not
  responding to the usual therapy
 Ketogenic Diet

 Vagal Nerve Stimulation (VNS)

 Surgery
 First Aid for Seizures

The main goal of care during a
seizure is to protect the child
from injury
Generalized Tonic Clonic
(Grand Mal) Seizures
   Remove objects in the way.
   Position child on his side to keep airway
    open (saliva and vomit cannot get into
    the lungs).
   Put something soft under the child’s
    head.
   Do NOT restrain – let seizure run its
    course.
Generalized Tonic Clonic
(Grand Mal) Seizures
   Do NOT put anything in the mouth.
   Stay with child – estimate the length of
    the seizure
   Let child rest until alert enough to be
    moved and/or return to normal activity
   Call 911 if seizure does not stop in 5-10
    minutes
Complex Partial Seizures
   Do NOT restrain but stay close to the
    child and protect him from harm –
    may wander unaware
   Let seizure run its course
   Let child rest until able to return to
    normal activity
Seizure Observations/Records
   Keep a diary of:
       Seizure frequency (how often)
       Description of event: Motor activity and
        level of responsiveness
            What happens before
            What happens during
            What happens after
       Length of seizure
Activity Restrictions
   Dangerous if the child loses consciousness
    during activity (child could be hurt)
   No tub baths unless supervised or watched.
   No swimming unless supervised.
   Biking, skateboards/scooters with helmet on
    non-busy streets
   No above ground activity – rope and tree
    climbing, jungle gyms
   No contact sports unless OK with doctor
   No driving unless OK with doctor
Other Safety Precautions
   Wear a medical identification bracelet
   Tell important people about history of
    seizures (teachers, babysitters, etc.)
   Educate these important people about
    seizure first aid.
Helpful Resources
   Your doctor or nurse
   Epilepsy Foundation of America
    www.epilepsyfoundation.org
    1-800-332-1000 or 1-800-efa-1000
   Indiana Epilepsy Services
    www.indianaepilepsy.org
   Books on Epilepsy for Parents and Children
    (see handout)
   www.medlineplus.gov
   Medical Alert: www.medids.com,
    www.americanmedical-id.com
Important Phone Numbers:
   911 (access to your local emergency
    services)
   Pediatric Neurology
    317-278-5450
   Riley Hospital Emergency or After Hours
    Phone 317-274-5000
“A person with epilepsy is a
person who just happens to
have epilepsy.”

      Epilepsy Poster 1985
Questions?
Febrile Seizures
   Happens in otherwise healthy children
    between 6 months and 5 years of age
   Average age 12-18 months
   Fever over 101o F
   Infection not involving central nervous
    system (ear infections, upper respiratory
    infection)
   1st seizure usually not treated unless
    complicated presentation
   Medicines of choice: Phenobarbital, Rectal
    Diazepam and Valproic Acid
Infantile Spasms/West
Syndrome
   Children under 12 months of age
   Peak onset is 4-6 months
   EEG pattern – hypsarrhythmia
   Cluster of head dropping down; arms
    extended then coming in like a hug,
    may have leg extension
Infantile Spasms/West
Syndrome
 Can have poor developmental prognosis
 Most have some form of brain damage

 Small number idiopathic (no cause)

Treatment of Choice:
 ACTH injections

 Vigabatrin – not approved in US

 Oral prednisone

 Other oral Antiepileptic Drugs (AEDs)

				
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