A paroxysmal disturbance in brain function

Seizures…part 1

:flying_saucer:Def. :a paroxysmal disturbance in brain function , manifests as an alteration in motor activity, level of consciousness, or autonomic function.

:flying_saucer:traditionally classified according to generalized or focal and preserved or impaired consciousness.

:flying_saucer:current system emphasizes diagnosis based on objective, measurable criteria.

:flying_saucer:status epilepticus :prolonged or recurrent seizures (without a return to consciousness) for 5 minutes or longer.

:flying_saucer:A number of nonepileptic paroxysmal disorders occur in childhood and must be distinguished from epileptic seizures.

:spiral_notepad:history :
1⃣description of the event is the most valuable part of the evaluation because physical findings are rare and diagnostic studies may not be conclusive. 2⃣the event was likely a seizure versus a nonepileptic event; a video recording is helpful.
3⃣:hot_face::crazy_face:aura, preceding mood or behavioral changes, a description of the event including motor, verbal, and autonomic changes (e.g., pupillary dilatation, drooling, incontinence, pallor, vomiting), 4⃣history of any inciting events (e.g., trauma, fever, crying).
5⃣medical history, a birth and developmental history. 6⃣medication use and ingestions of toxic substances. 7⃣children with a known seizure disorder ask about medication compliance.

:woman:t2:‍⚕physical examination :
Neurocutaneous lesions (e.g., café-au-lait spots, ash leaf macules) and vascular lesions .

:ambulance: ((simple febrile seizures)) are benign events with excellent long-term prognoses.
:point_right:t2:2-5% of population ; of those, 30% will have a recurrence.
:point_right:t2:risk of subsequent epilepsy is low , predictors : age of occurrence, duration of fever, height of fever, family history.

:robot:Complex febrile seizures : focal or prolonged (longer than 15 minutes) or repetitive episodes during the febrile illness.

:bulb::bulb:(Remember, children younger than 6 months of age do not meet the criteria for a simple febrile seizure and should not be evaluated along this pathway.)

:studio_microphone::studio_microphone:evaluation of complex febrile seizures individualized on the presentation.
:point_right:t2:A very prolonged seizure,
:point_right:t2:a focal seizure (characteristic of herpes simplex virus [HSV] encephalitis diagnosed by PCR for HSV performed on a spinal fluid specimen),
:point_right:t2:abnormal neurologic examination prompt a thorough evaluation for a CNS infection. tests for bacterial and viral etiologies of meningitis.
:point_right:t2:MRI for all children with a focal seizure.
:point_right:t2:EEG obtained acutely if concerned about febrile status epilepticus.

:studio_microphone:the term complex febrile seizure applies to children between 6 months and 60 months of age. :point_right:t2:Outside of that age group, seizures with fever can be due to multiple other causes (e.g., HHV6, Shigella, immunizations).
:syringe:A lumbar puncture is not routinely recommended for a child age 6-12 months (who is well appearing and fully immunized) who has experienced a simple febrile seizure because their risk of having bacterial meningitis is extremely low.

:pill::pill:recommendation for performing an LP on a child had antibiotics (by any route) in the days preceding the seizure or whose immunization status is unknown or deficient (particularly for Hib and pneumococcus, which are known pathogens for bacterial meningitis).

:face_with_monocle:infants younger than 2 months with seizures requires consideration of causes mostly unique to the neonatal age group.

.:woman:t2:‍⚕:arrow_forward:The presence of autonomic symptoms, :arrow_forward:altered level of consciousness,
:arrow_forward:lack of suppression with gentle restraint,
:arrow_forward: history of CNS insult or injury should raise suspicion of seizures.

:pouting_woman:t2:‍♂Older children experiencing seizures may manifest abnormal vocalizations, incontinence, or a change in mood or behavior preceding the event.

:camera_flash:A nonepileptic event is suggested by abrupt resolution with return to full level of consciousness (LOC) or when the movement ceases abruptly when children can be aroused from sleep.

(1) :cold_sweat:((Breath-holding spells ))should distinguished from seizures.

:cold_sweat: Cyanotic or “blue” breath-holding spells is prolonged expiratory apnea or a sudden lack of inspiratory effort, often during crying.

:disappointed_relieved: pallid breath-holding spells, a reflex vagal-bradycardia usually following a minor injury.

:cold_sweat:triggered by injury, anger, or frustration.

:cold_sweat: Apnea, brief loss of consciousness, tonic posturing, anoxic seizures can follow.

:cold_sweat:typically occur between ages 6 and 18 months, may be seen in children up to 6 years.

:cold_sweat:Children recover quickly, no diagnostic evaluation is indicated.

:cold_sweat:children should be assessed for iron deficiency, and treated if present.

(2) :face_with_head_bandage:((Head banging)) (jactatio capitis nocturna) rhythmic to-and-fro movements of the head and body.
:face_with_head_bandage:Children have no memory of this behavior, occurs on going to sleep.
:face_with_head_bandage:resolves by 5 years of age.

(3) :alarm_clock:((Myoclonus)) brief involuntary muscle “jerk”;
:alarm_clock:its clinical significance based on whether occurring as an isolated involuntary movement or as a component of a more complex epilepsy syndrome or movement disorder.

:alarm_clock:common and benign in sleeping infants (neonatal sleep myoclonus).

:alarm_clock:distinguished from seizures by occurring only during sleep and ceasing when the infant wakes up, and absence of any autonomic symptoms.
:alarm_clock:resolves by 2 to 3 months of age.

(4) :robot:((hyperekplexia )) (stiff baby syndrome or startle disease) may have nocturnal myoclonus, stiffening upon awakening, exaggerated startle reflex, and apnea.
:robot:A few children may continue throughout life.