Approach to seizures

Shahad Al-malki
Supervised by: Pro.Jan
Patient’s file number: (1019810)

Chief complaint: abnormal involuntary movements for a duration of 2 days.

Problem list: (pertinent past medical history)

RAYAN a 13 years old male, known of :

• Global development delay,
• seizure disorder on Tegretol(carbamazepine) 400 mg bid (17 mg/kg),
• not compliant to his medication (not taken for the past 11 days).
History of Present Illness:
came on May 1,2018 with history of recurrent seizure activity for 2 days and drop in conscious
level . The history of present illness started 4 days back, when he started to develop generalized
tonic-clonic, with up-rolling of eyes, and frothy secretions, lasting 1 min, occurring every hour,
with no regaining consciousness.

the patient had last seizure at 10 am, then the parents noticed buccal movements and reduced
level of consciousness than usual. there is positive subjective fever at home, and 1 documented at
Alahli hospital 40C before coming to our hospital where he received IV-fluids and antipyretic.

he is not compliant on medications due to low socioeconomic status.

the patient had his first seizure at the age of 3.5 years old only once, did not seek medical advice due to low
socioeconomic status, and started to deteriorate as he stared to not walk, then crawl, and did not gain any more
vocabularies. he had his second seizure at the age of 5 years, was started on Tegretol at Baksh hospital, he usually
have seizures once per week lasting 1 min tonic clonic. not following up regularly. the patient lost almost 15 kg over
the last 6 months.

Hx of decrease in oral intake and activity for 2 days.

Hx of contact with other sick member family.
No urinary symptoms (No suprapubic pain, no painful micturition, no change of urine colour or odours, no
urgency).
No hx of cyanosis, or dysphagia, or drooling.
No change bowel habit, or vomiting, or diarrhea, or abdominal pain..
No hx of trauma .
No hx of aspiration.
Past medical hx: -Known developmental delay and seizure disorder.
Vaccination hx: mother is not sure about vaccination.
Surgical hex: Non
Medications allergic hx: Non
Family hx: -Negative consanguinity. They have 7 healthy children at home.
Vital signs:

Test Result

Temp 39.4

HR 152

RR 24

BP 113/71

O2 saturation 96
physical exam findings:

Looked not oriented with abnormal mouth and right hand movement, well hydrated, no (respiratory distress, or
dysmorphic features, pallor or cyanosis).

Pupil: equal and reactive.

CNS:GCS 8/15, normal tone in upper limbs, flexed legs (as at home) power could not
be assessed, reflexes were not detected.

Eye: no redness, or discharge, or signs of conjunctivitis.

ENT: no congested throat, clear ears.

Neck: no neck pain, torticollis or limitation of movement at all direction, Non-significant

cervical and sub-mandibular lymphadenopathy.

Chest: bilateral Equal air entry, no add sounds.

Cardiac: s1, s2 normal and no audible murmur, Cap refill less than 2 seconds.

Abdomen: soft, lax, no organomegaly, and no tender or rebound tender at RT iliac fossa.

Skin: no skin rash, no bleeding or ecchymosis, or purpura.

Blood Glucose: 8.9MMOL (extremely low, danger of unconsciousness).

Initial impression: CNS infection.

Relevant labs/ studies:

• CBC
• Liver function test
• Urea and electrolyte
• Bone function profile
• CRP
• Bacterial and fungal culture-blood (no growth)
• Bacterialculture-urine
 INVESTIGATION:

CBCand differential

Normal
Test Result
range
16.5-21.5
Hemoglobin (Hg) 15.0
g/dl
Hematocrit (HCT) 45.5 41-50 %

White Blood Cell (WBC) 19.73 4-11 k/ul

Automated Lymphocytes (%) 22.6 high

 INVESTIGATI
ON:

Bone function profile

Test Result Normal range
2.12-2.52
Calcium 1.29
mmol/l
0.81-1.58
Phosphate 1.00
mmol/l
 INVESTIGATI
ON:

Liver function test

Test Result Normal range

Total protien 89 64-82 g/L

Alkaline phosphate 745 156-368 U/L

Aspartate Amino Transferase 106 15-37 U/L

Alanine Amino Transferase 34 12-78 U/L

Gamma-glutamyl Transferase 25 5-85 U/L

Bilirubin – total 16 0-17 g/L

Albumin 42 40.2-47.6 g/L

 INVESTIGATI
ON:

Urea and electrolyte

Test Result Normal range
136-145
Sodium 148
mmol/L
3.5-5.1
Potassium 3.6
mmol/L
98-107
Chloride 116
mmol/L
2.5-6.4
Urea 9.8
mmol/L
Creatinine 83 53-115 umol/L
 INVESTIGATI
ON:

Test Result Normal range

CRP 113 0-3 mg/L

Bacterial and fungal culture-

No growth
blood

Bacterial culture-urine No growth

 Test Result

Parathyroid Hormone (PTH) 30.87 high

Vitamin D total (25-OH-Vitamin D3) 39.1 low

Test Result

CSF-glucose 5.6 high

Micro Latex test-CSF negative

CT – BRAIN (Nonenhanced):
No acute brain insult

MRI:
there is diffuse thickening and enhancement of the dura.
plan:
• Midazolam 5 mg/1ml Ampule.
• Paracetamol 1000 mg/100ml Vial.
• Phenytoin Na 250 mg/5mL Ampule.
• ceftriaxone Paediatric Infusion.

final diagnosis:
• viral encephalitis
• Vitamin D deficiency.
• Disorders of calcium metabolism.
OBJECTIVES:

 Define Epilepsy and seizure.

 Recognize the causes, types and differential diagnosis in a child with seizure.
 Identify the criteria for diagnosing a child with Febrile Seizures.
 Formulate an approach to a child with seizure (febrile vs afebrile) including history, examination, investigations and
treatment.
 CAUSES OF SEIZURES
 seizure epilepsy
defined by any of the following conditions:

Is a transient occurrence of signs

and/or symptoms due to 1. At least 2 unprovoked seizures separated by more than 24
abnormal excessive electrical hours.
discharge from the brain.

2. One unprovoked seizure with an underlying predisposition to

seizures. (and recurrence risk over the next 10 years is similar
to the recurrence risk after 2 unprovoked seizures).

3. Diagnosis of an epilepsy syndrome.

 Perinatal Infections Metabolic Conditions

• Malformation of cortical • Encephalitis • Hypoglycemia

development. • Meningitis • Hypocalcemia
• Intrauterine infection • Brainabscess • Hypomagnesemia
• Hypoxic-ischemic encephalopathy • Hyponatremia
• Trauma • Hypernatremia
• Hemorrhage • Storage diseases
• Reye syndrome
• Degenerative disorders
• Porphyria
• Pyridoxine dependency and deficiency
Poisoning Neurocutaneous Systemic Disorders
Syndromes

• Lead • Tuberous sclerosis • Vasculitis

• Drug toxicity • Neurofibromatosis • Systemic lupus erythematosus
• Drug withdrawal • Sturge-Weber syndrome • Hypertensive encephalopathy
• Incontinentia pigmenti • Hepatic encephalopathy
Other Conditions

• Accidental trauma
• Child abuse
• Increased intracranial pressure
• Tumor
• Remote brain injury
• Febrile illnesses
• Cryptogenic (no underlying disorder
found)
• Familial
 CLASSIFICATION OF
SEIZURES ACCORDING
TO

The International League Against Epilepsy

 Seizure

Generalized Focal

Primary
Simple partial
generalized

Secondary Complex
generalized partial

Simple evolves
to complex

Unclassifiable
 Simple partial Seizures Complex partial Seizures Simple evolves to complex

Preictal phase: • Simple partial onset followed by

aura impairment of consciousness.
Ictal phase: • Impairment of consciousness at
• motor symptoms: onset.
forceful turning of eyes or head, focal
muscle rigidity/jerking, Jacksonian march.
Preictal phase:
Aura (déjà vu, jamais vu )
• somatosensory or special-sensory
symptoms. Ictal phase:
• Automatisms:
• With autonomic symptoms: lip smacking, pulling at
epigastric discomfort, sweating. clothing, scratching, running,
and other stereotypic
• With psychic symptoms. movements

Postictal: Postictal:
• Consciousness is preserved. • Consciousness is impaired.
• patient remember what happened. • Memory loss for what happened.
 Seizure

Idiopathic
symptomatic
(genetic)

Neurologically and developmentally

normal '(developmental) epileptic encephalopathy’: epilepsy is
a symptom for underling disease such as :
- Tuberous sclerosis.
-tumour.
-hypoxic od ischemic insult.

Unknown

-used to called cryptogenic.

-patient neurologically and developmentally abnormal.
-it has the worst prognosis because there are no
genetic ground or cause and he is abnormal.
 Approach to a Child with Febrile Seizures
Definition ( Criteria of diagnosis):
The American Academy of Paediatrics announced a standard
definition of febrile seizures as a :

• seizure occurring in febrile children between the ages of 6 and 5

years.
• NO intracranial infection,
• NO metabolic disturbance.
• NO history of afebrile seizures.
Risk factors:

( Strong )
• temperature elevation above 37.8°C.
• young age 6 mo – 5 yr.
• family history of febrile seizures.
• viral or bacterial infection outside the central nervous system.

(Weak)
• male sex.
• Vaccinations.
• antenatal exposure to nicotine.
• iron deficiency.
Consciousness is recovered quickly, within 30 minutes.

*Febrile seizures are considered complex if at least one of the criteria are met
Step-by-step diagnostic approach:

Differential diagnosis:

1. Acute bacterial meningitis

2. Viral meningitis
3. Viral encephalitis
4. Acute encephalopathy
5. Epileptic seizure
6. Generalised epilepsy with febrile seizures plus (GEFS+)
7. Hot water epilepsy (HWE)
8. Breath-holding spells
9. Severe myoclonic epilepsy of infancy
 Questions to ask in Hx taking :

Was it really a seizure? If yes, what type – typical or atypical?

Ask a witness to describe the child’s activity, specifically ask about:

before the seizures: Ictal:

• Trigger. •Loss of consciousness.
- Fever. •Duration.
- Fall. •Automatisms.
- Medication •Motor symptoms.
- Miss his medication -localized movements or paralysis.
- Vomiting. -whole body stiffness or shaking
- Current viral illness •Perioral cyanosis, any skin colour changes.
- Recent immunizations(DTP,MMR) •Loss of bladder and bowel control.
•How many episodes.
Pre-ictal
• aura.
- abdominal discomfort.
- fear.
- unpleasant sensations.
Post-ictal: past medical history:
•Asleep or awake. •Any seizures before or Febrile seizures.
•neurologic deficit •Current medical conditions.
-Visual field defect. •Head trauma.
-Weakness. •Previous neurological deficits.
•Headache.
•Medications that may lower the seizure threshold.
•Ask about neonatal history.
•Symptoms of meningitis.
•Developmental delays.
•Symptoms of encephalitis.
•Family history of seizures.
Physical examination:

• Neurological examination normal postictally.

Physical signs are as follows:

• extracranial infection and fever (e.g., upper respiratory
infection, otitis media, gastroenteritis).
• absence of nuchal rigidity and focal neurological
abnormalities.
• rapid recovery of consciousness after seizure .
Investigations:
Investigations:

EEG and MRI may be helpful in:

• diagnosis with recurrence of complex febrile seizures.
• prolonged impairment of consciousness after seizure (>60 minutes).
• or abnormal neurological signs.

American Academy of Pediatrics does not recommend routine serum electrolytes after a first
simple febrile seizure.

CBC Not routinely recommended, but may be required to determine the cause of fever.
 Management:

• the patient should be protected from physical injury.

• Most seizures will stop spontaneously within a few minutes, and anticonvulsant therapy is not needed.

• Reassure parents and educate them about:

- The risk of non-febrile seizures and epilepsy is small.
- Some children have a susceptibility to febrile seizures that resolves before the age of 6.
- If a seizure develops and lasts longer than 3 to 5 minutes, child should be taken to the nearest hospital.
-Rectal diazepam at a dose of 0.5mg/kg (max 10 mg) may be given to help terminate seizures lasting > 5 minutes.
Reference:
BMJ.
Nelson essential of paediatric.
Illustrated of paediatric.