Once it is determined that the child has had a seizure, it is important to distinguish whether the episode was an epileptic or a nonepileptic seizure. Seizures are the indispensable characteristic of epilepsy; however, not every seizure is epileptic. Epilepsy is a condition characterized by two or more unprovoked seizures. A simple seizure event should not be classified as epilepsy and is generally nor treated with long-term antiepileptic drugs. Some seizures may result from an acute medical or neurologic illness and cease once the illness is treated. In other cases children may have a single seizure without the cause ever being known.
Etiology and Classification
Seizure disorders are considered symptomatic (ie, a symptom of a known cause such as a brain tumor or stroke or idiopathic. Idiopathic seizure disorders probably have some genetic basis.
Seizures are classified as generalized, partial or unclassified epileptic seizures. In generalized seizures, the aberrant electrical discharge diffusely involves the entire cortex of both hemispheres from the onset, and consciousness is usually lost. Generalized seizures result most often from metabolic disorders and sometimes from genetic disorders. Generalized seizures include infantile spasms and absence, tonicclonic, atonic, and myoclonic seizures.
Partial seizures (those of focal onset) are often due to structural abnormalities. The excess neuronal discharge begins in one cerebral cortex. Partial seizures may be simple (no impairment of consciousness) or complex (reduced but not complete loss of consciousness). Partial seizures may spread and activate the entire cerebrum bilaterally, manifesting as a generalized seizure. Activation may occur so rapidly that the initial partial seizure is not clinically apparent, or a generalized seizure may follow a brief partial seizure (called secondary generalization).
Idiopathic seizure disorders generally begin between ages 2 and 14. Incidence of symptomatic seizures is highest at birth and among the elderly. Seizures before age 2 are usually caused by developmental defects, birth injuries, or metabolic disorders. Many seizures that begin in adults are secondary to cerebral trauma, alcohol withdrawal, tumors, or cerebrovascular disease; for 50% of seizures, cause is unknown.
Seizure disorders in the elderly are often due to tumors or strokes. Posttraumatic seizures occur after 25 to 75% of head injuries that cause skull fractures, intracranial hemorrhages, or focal neurologic deficits.
Sometimes patients with psychiatric disorders simulate seizures (called nonepileptic seizures or pseudoseizures).
Classification and Manifestations
Seizures may be preceded by an aura of sensory or psychic manifestations (eg, smell of rotting flesh, stomach butterflies). Most seizures end spontaneously in 1 to 2 min. A postictal state may follow a seizure (most commonly, generalized) and is characterized by deep sleep, headache, confusion, and muscle soreness; this state lasts from minutes to hours. Sometimes the postictal state includes Todd’s paralysis, a transient neurologic deficit on the side contralateral to the seizure focus.
Most patients appear neurologically normal between seizures, although high doses of anticonvulsants can reduce alertness. Any progressive mental deterioration is usually related to the neurologic disorder that caused the seizures rather than seizures themselves. Rarely, seizures are unremitting.
1. Partial seizures:
Simple partial seizures: Motor, sensory, or psychomotor symptoms occur without loss of consciousness.
Specific symptoms reflect the affected area of the brain. In jacksonian seizures, focal motor symptoms begin in one hand, then march up the arm. Other focal seizures affect the face first, and then spread to an arm and sometimes a leg. Some partial motor seizures begin with an arm raising and the head turning toward the moving arm. Some proceed to generalized convulsions.
Complex partial seizures: An aura often precedes the seizure. During the seizure, patients may stare, perform automatic purposeless movements, complete unintelligible sounds without understanding what is said, and resist assistance. Consciousness is impaired, but patients have some awareness of the environment (eg, they purposefully withdraw from noxious stimuli). Motor symptoms subside after 1 to 2 min, but confusion and disorientation may continue for another 1 or 2 min.
Patients may lash out if restrained during the seizure or while recovering consciousness after a generalized seizure. However, unprovoked aggressive behavior is unusual.
Left temporal lobe seizures may cause verbal memory abnormalities; right temporal lobe seizures may cause visual spatial memory abnormalities. Incidence of psychiatric disorders is higher in patients with a temporal lobe seizure than in the general population: 33% have psychologic difficulties, and 10% have schizophreniform or depressive psychoses.
Between seizures, many patients develop new behaviors, such as religiosity, hypergraphia (compulsion to write copiously), extreme dependence on other people, and altered sexuality.
Secondarily generalized Partial Seizures: simple or complex partial seizures may spread and become generalized, usually into a tonic-clonic seizure.
2. Generalized seizures: Consciousness is usually lost, and motor function is abnormal from the onset.
Generalized tonic-clonic: (sometimes called primarily generalized or grand mal ) seizures typically begin with an outcry; they continue with loss of consciousness and falling, followed by tonic, then clonic contractions of muscles of the extremities, trunk, and head. Urinary and fecal incontinence and frothing at the mouth sometimes occur. Seizures usually last 1 to 2 min. Secondarily generalized tonic-clonic seizures begin with a simple partial or complex partial seizure.
Absence seizures or petit mal: Temporary lapse of consciousness that starts and ends abruptly. Brief periods of lack of awareness; may be unusual movements. The usual age of onset is 4 to 8 years. It has high genetic predisposition. Over 50 percent go into remission after adolescence and generally normal IQ; only 5 percent retarded
Atonic seizures occur in children. They are characterized by brief, complete loss of muscle tone and consciousness. Children fall or pitch to the ground, risking trauma, particularly head injury.
Myoclonic seizures are brief, lightning-like jerks of a limb, several limbs, or the trunk. They may be repetitive, leading to a tonic-clonic seizure. Unlike other seizures with bilateral motor movements, consciousness is not lost unless a generalized seizure occurs.
Juvenile myoclonic epilepsy appears during childhood or adolescence. Seizures begin with a few bilateral, synchronous myoclonic jerks, followed in 90% by generalized tonic-clonic seizures. They often occur on awakening in the morning, especially after sleep deprivation or alcohol use.
unclassified epileptic seizures : Infantile spasms are characterized by sudden flexion of the arms, forward flexion of the trunk, and extension of the legs. Seizures last a few seconds and recur many times a day.
They occur only in the 1st 5 yr of life, then are replaced by other types of seizures. Developmental defects are usually present.
Status epilepticus: Generalized convulsive status epilepticus is tonic-clonic seizure activity lasting > 5 to 10 min or ≥ 2 seizures between which patients do not fully regain consciousness. The previous definition of > 30 min duration was revised to encourage more prompt identification and treatment. Untreated generalized seizures lasting > 60 min may result in permanent brain damage; longer-lasting seizures may be fatal. There are many causes, including rapid withdrawal of anticonvulsants. Complex partial and absence status epilepticus often manifest as prolonged confusion. Treatments include: Diazepam, 0.3 mg/kg to 5mg if < 5 years old and 0.3 mg/kg to 10mg if > 5 years old. Administer diazepam slowly.
Anticipate respiratory arrest, hypotension. Rectal route is alternative when vascular access cannot be obtained
Evaluation must determine whether a seizure (vs, eg, syncope, cardiac arrhythmia, or drug overdose) occurred, then identify possible causes or precipitants. Patients with new-onset seizures are evaluated in an emergency department; they can sometimes be discharged after thorough assessment. Those with a known seizure disorder may be evaluated in a physician’s office.
History: Classic seizure activity, bitten tongue, incontinence, prolonged loss of consciousness followed by confusion, or presence of aura suggests a seizure. History should include information about the 1st and subsequent seizures (eg, duration, frequency, sequential evolution, longest and shortest interval between seizures, aura, postictal state, precipitating factors). Risk factors for seizures (eg, prior head trauma or CNS infection, known neurologic disorders, drug use or withdrawal, anticonvulsant noncompliance, family history of seizures or neurologic disorders) should be identified.
Physical examination: Physical examination is almost always normal when seizures are idiopathic but may provide significant findings when seizures are symptomatic. Fever and stiff neck suggest meningitis, subarachnoid hemorrhage, or encephalitis. Papilledema suggests increased intracranial pressure. Focal neurologic defects (eg, asymmetry of reflexes or muscle strength) may indicate a structural abnormality (eg, tumor). Skin lesions may indicate a neurocutaneous disorder (eg, axillary freckling or café-au-lait spots in neurofibromatosis, hypomelanotic skin macules or shagreen patches in tuberous sclerosis).
Testing: For patients with a known seizure disorder and a normal or unchanged neurologic examination, little testing is required except for blood anticonvulsant levels, unless symptoms or signs of trauma or a metabolic disorder are present.
For patients with new-onset seizures or with a newly abnormal neurologic examination, head CT is required immediately to exclude a mass or hemorrhage. Follow-up MRI is recommended when CT is negative; it provides better resolution for brain tumors and abscesses and can detect cerebral venous thrombosis and herpes encephalitis. Laboratory tests for metabolic disorders should be done, including CBC; serum glucose, BUN, creatinine, Na, Ca, Mg, and P; and liver function tests. If meningitis or CNS infection is suspected in any patient, head CT is done, and if it is normal, a lumbar puncture is required.
EEG is done; it may be needed to diagnose complex partial or absence status epilepticus. Alert and oriented patients with normal imaging and laboratory tests can undergo EEG as outpatients.
In complex partial seizures of temporal lobe origin, temporal lobe foci (spikes or slow waves) occur between seizures (interictal). In generalized-at-onset tonic-clonic seizures, interictal EEG abnormalities may manifest as symmetric bursts of sharp and slow, 4- to 7-Hz activity. In secondarily generalized seizures, the EEG may show focal electrical discharges. In absence seizures, spikes and slow-wave discharges appear at a rate of 3/sec. In juvenile myoclonic epilepsy, a 4- to 6-Hz polyspike and wave abnormality is characteristic.
However, diagnosis is clinical and cannot be excluded by a normal EEG. EEG is less likely to detect abnormalities if seizures are infrequent. Of patients ultimately confirmed to have a seizure disorder, 30% have a normal 1st EEG; a 2nd EEG done after sleep deprivation detects abnormalities in 1?2. Some patients never have an abnormal EEG.
Inpatient combined video-EEG monitoring for 1 to 5 days may help determine type and frequency of seizures (eg, frontal lobe seizure vs a pseudoseizure) and guide treatment.
Prognosis and Treatment
With treatment, seizures are eliminated in 1?3 of patients, and frequency of seizures is reduced by > 50% in another 1?3. About 60% of patients whose seizures are well-controlled by anticonvulsants can eventually stop the drugs and remain seizure-free.
Optimal treatment is to eliminate the causes whenever possible (see elsewhere in the manual). If the cause cannot be corrected or identified, anticonvulsants are often required, particularly after a 2nd seizure; usefulness of anticonvulsants after a single seizure is controversial, and risks and benefits should be discussed with the patient.
During a seizure, injury should be prevented by loosening clothing around the neck and placing a pillow under the head. Attempting to protect the tongue is futile and likely to damage the patient’s teeth or the rescuer’s fingers. Patients should be rolled onto their side to prevent aspiration.These measures should be taught to the patient’s family members and coworkers.
Until seizures are controlled, patients should refrain from activities in which loss of consciousness could be life threatening (eg, driving, swimming, climbing, bathing in a bathtub). After seizures are completely controlled (typically for > 6 mo), many such activities can be done if appropriate safeguards (eg, lifeguards) are used, and patients should be encouraged to lead a normal life, including exercise and social activities. In a few states, physicians must report patients with seizures to the Department of Motor Vehicles. However, most states allow automobile driving after seizures have been absent for 6 mo to 1 yr.
Cocaine and some other illicit drugs (eg, phencyclidine, amphetamines) can trigger seizures and should be avoided. Alcohol intake should be minimized. Some drugs (eg, haloperidol, phenothiazines) may lower seizure threshold and should be avoided if possible. Family members must be taught a commonsense approach toward the patient. Overprotection should be replaced with sympathetic support that lessens negative feelings (eg, of inferiority or self-consciousness); invalidism should be prevented. Institutional care is rarely advisable and should be reserved for severely retarded patients and for patients with seizures so frequent and violent despite drug treatment that they cannot be cared for elsewhere.
Definition. Febrile seizures are convulsive events that are considered benign (not associated with serious difficulties), occurring between 6 months and 6 years of age. The typical febrile seizure is a convulsive event that lasts about one to five minutes. This usually occurs with the rapid rise of the fever and consists of a rhythmic jerking of the extremities, eye rolling, unresponsiveness, sometimes cyanosis (bluish discoloration around the mouth and the tips of the extremities), followed by 30 minutes of drowsiness and confusion. As the temperature normalizes, the child may return to his normal self. An occasion, a febrile seizure may occur differently, non-convulsive (without shaking), presenting a loss of tone and consciousness or with stiffening of the body.
Complex features. Some children may have complex febrile seizures. Complex features include the following:
· Duration, more than 20 minutes
· Focality when the seizure occurs on one side of the body
· Multiplicity, when more than one seizure occurs during a 24-hour period
The significance of the complex features is that of a higher risk for future epilepsy; the more complex the features, the higher the risk for epilepsy or seizures without fever. Generally if a child has a simple febrile seizure the risk for epilepsy is 2% compared to 1% in the general population. The risk for future febrile seizures is about 30%, or 50% if the first seizure occurred before one year of age. Also, the lower the temperature that provoked the first febrile seizure is, the higher the risk for future febrile seizure events.
Treatment. Treatment for febrile seizures is usually unnecessary. Lowering of the temperature with Tylenol or Motrin is usually ineffective. Anticonvulsants may be used in unusual situations, usually continuous Phenobarbithal or Depakene (Depakene after 3 years of age). Oral valium as premedication, given intermittently during febrile illnesses is highly effective and does not require continuous medication administration and monitoring. This is my first choice for febrile seizures that require treatment.
Long-term effects. Febrile seizures are not considered to cause any damage to the brain. Studies have shown no difference in intelligence between children who suffer from febrile seizures or their siblings (or identical twins) who do not have febrile seizures. Some recent studies even suggest improved memory function in children who have had febrile seizures.
Complications. Complications from febrile seizures are rare and are mostly associated with focal and prolonged febrile seizures. Future epilepsy, especially with recurrent focal seizures, was reported.
Respiratory compromise is rare and may be caused by prolonged convulsions affecting the respiratory muscles and breathing.
In an individual who suffers from seizures, one of the most important things to avoid is drowning.
Drowning is one of the most common causes of death from Epilepsy. It is very important to ensure that a person with seizures will not be left alone in the water; (bathtub, Jacuzzi or pool) without supervision.
Also people with Epilepsy should not go on a small boat without a partner in order to avoid falling overboard during a seizure and drowning.
The other thing to avoid is unnecessary head trauma. A person with Epilepsy should try to avoid engaging in sports that predispose one to repeated head injury (such as boxing). The question is less clear when it comes to other sports.
Check ABC’s, suction PRN
Assure good oxygenation, ventilation
Check blood glucose, if < 70, give D25W
If febrile, remove excess clothing, sponge with water to cool patient.