Peds Case 19- 16M/o W First Seizure

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causes of unresponsiveness in children

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seizures,
syncope (breath-holding spells/arrhythmia),
infection (meningitis/encephalitis),
toxic ingestions/poisoning,
head trauma with loss of consciousness.

Less common
intracranial processes (tumor/hemorrhage)
intussusception.

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seizures

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common in children
paroxysmal neurologic events variable: generalized or partial seizures
causes: Metabolic disturbances (hypoglycemia or hypocalemia)
head trauma resulting in cerebral contusion or intracranial hemorrhage
developmental abnormalities of the brain or genetic syndromes which involve the brain such as tuberous sclerosis
many are idiopathic

Some only one seizure in their lifetime. others recurrent= epilepsy (two or more unprovoked seizures)
prevalence of approximately 1% throughout childhood

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syncope

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breath-holding spells common in 1-3 years.
cyanotic (more common) or pallid type

cyanotic: precipitating event that upsets, resulting in vigorous crying and hyperventilation, prolonged expiratory apnea. Transient hypoxia= pale or cyanotic, brief loss of consciousness, limpness. quickly self-resolve and no post-ictal state. Occasionally, after breath holding spell may have a brief generalized seizure, most likely due to hypoxia. reassured that breath holding spells are a benign and self-limited condition. Very rarely, associated w asystole.

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cardiac syncope

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more unusual in this age patient, but should be considered
most likely not be vasovagal syncope.

However, cardiac causes such as supraventricular arrhythmias (Supraventricular Tachycardia) or ventricular arrhythmias (in the setting of prolonged QT syndrome) can decrease cerebral blood flow and cause syncope.

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infectious

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30-40% of children with meningitis can present with seizure activity.
Fever and irritability may be the only signs
encephalitis frequently present w fever and seizure

After seizure not return to baseline and remain impaired

Enteroviral infections and herpes simplex virus for encephalitis

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toxic ingestions

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9 months- 3 years.
more opiates, benzodiazepines, and clonidine. metabolic disturbance such as oral diabetic agents causing hypoglycemia

Closed head injury (with or without intracranial injury) may lead to loss of consciousness. not witnessed maybe.

brain tumor can lead to both seizures or more global alterations in mental status.
preceding history of headache, behavior change or vomiting. Brain tumors are the most common solid tumors in childhood
usually in the posterior fossa
most likely begin as a partial seizure. The presence of fever makes these less likely

Acute alcohol poisoning and more longstanding lead poisoning

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intussussception

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telescoping or prolapsing of a portion of the intestine within another immediately adjacent portion of intestine –
usually terminal ileum into the colon.

Repeated episodes of colicky pain
more long-standing= lethargy with a near unresponsive state between the episodes of colicky pain.
intravascular volume depletion due to vomiting and third spacing of fluids= mental status changes

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suspicious sx of seizures

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oss of consciousness, tongue biting, incontinence, eyes rolling to the back of the head, pinpoint pupils and a post-ictal state are all supportive evidence for a seizure. In addition, children who are old enough to verbalize may describe an aura or "premonition" prior to the onset of a seizure.

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generalized tonic-clonic seizure

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most common type seen in children
begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes.
Clonic jerks of all extremities follow the tonic phase. Finally, the child becomes flaccid and urinary incontinence may occur

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simple partial seizure

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motor signs in a single extremity or on one side of the body.
focal onset seizure activity may spread to become generalized, making it difficult to distinguish from a generalized seizure.

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complex partial seizure

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at any age.
Alteration of consciousness hallmark features.
localize around the eyes (glassy-eyed), the mouth (lip-smacking, drooling, gurgling), and the abdomen (nausea and vomiting).
Automatisms are quasi-purposeful motor or verbal behaviors that are repeated inappropriately and commonly accompany complex partial seizures

30 seconds to 2 minutes and postictal confusion, sleep, or headache
Secondary generalization can occur in up to one third of children,so ask about initial features to help differentiate a complex partial seizure from a generalized seizure

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absence epilepsy (petit mal seizures).

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starting around age three. Absence seizures are characterized by loss of environmental awareness ("staring off into space") and automatisms (e.g., eye-fluttering or lip-smacking). While these are generalized seizures, children usually regain their consciousness more quickly than the postictal phase seen in a generalized tonic-clonic seizure. Absence seizures are not associated with loss of tone or urinary continence. Absence seizures can be precipitated by hyperventilation or photic stimulation.

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Atonic (akinetic) seizures

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loss of motor tone

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febrile seizures

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Febrile seizures are usually generalized seizures.
2-4% 6 months- 5 years.
distinction bw common, benign condition of febrile seizures and more serious meningitis or encephalitis (CNS infections directly involve the brain or the meninges surrounding the brain). febrile seizures, typically a benign and self limited illness like a viral infection causes fever which can trigger a seizure in a susceptible host (young child, positive family history, etc).
Prolonged fever prior to the event, especially with irritability or inconsolability, is an indication of a more serious CNS condition causing the seizure.

In patients with very prolonged seizures, fever may be due to sustained motor activity and possibly the release of inflammatory mediators

Parents' subjective assessment of fever has been shown to agree with the presence of fever (T >38 degrees C or 100.4 degrees F) in 80% cases

ever and the seizure are coincidental?
febrile seizure can be difficult differentiate from epilepsy. Every child with epilepsy has to have a first seizure at some point and the inciting event may be a mild infection with fever

most children with febrile seizures to be developmentally normal. Pre-existing developmental abnormalities are a risk factor for subsequent epilepsy.

febrile seizures are hereditaryautosomal dominant, polygenic, and multifactorial

usually first day of the illness, often as the first sign to the parents that the child is ill (>38)
developmentally normal and often have a positive family history for other first degree relatives with febrile seizures as children.
generalized

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seizures result from excessive neuronal activity in the brain.
other conditions result in mvmts mimicing seizures

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seizures result from excessive neuronal activity in the brain.
other conditions result in mvmts mimicing seizures -- such as motor tics, myoclonus, gastroesophageal reflux (Sandifer's syndrome), and pseudoseizures- psycogenic seizues, physical manifestations of psyc disturbances (adolescents or adults)

ask whether the child was distractible, and if the event could be interrupted.
older kids may describe an aura or "premonition" prior or caregivers notice unusual behavior just prior

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natal factors in seizures

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intrauterine congenital infections such as cytomegalovirus and toxoplasmosis may lead to microcephaly, developmental delay and seizures
teratogens
Perinatal complications such as asphyxia may be associated with neurologic abnormalities
Premature infants are at risk for intracranial hemorrhages if severe,
Medical complications in the neonatal period such as infection (neonatal meningitis), prolonged hypoglycemia, and kernicterus

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meningitis/encephalitis

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seizures
other signs of illness such as vomiting, lethargy or behavior change

Very young infants (<3-6 months) with bacterial meningitis may not show any signs of nuchal rigidity
overall risk of meningitis is low in children who present with a simple febrile seizure
LP strongly reccommended in unvaccinated children 6-12 months old (>12mos you can recognize sx better)

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epilepsy

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fever often triggers the first seizure in children with epilepsy. Although some children with epilepsy also have developmental delay due genetic, congenital or acquired disorders (symptomatic epilepsy), many other children with epilepsy are developmentally normal (idiopathic epilepsy)

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post-traumatic seizures

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1-2 hours after a mild head injury

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truncal ataxia

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b/c midline cerebellar dx
cannot sit unsupported

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toxic child characteristics

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Has poor or absent eye contact.
Fails to recognize caregivers.
Is very irritable and cannot be consoled or distracted.
Has a minimal response to painful procedures, such as an IV placement or blood draw.
Has signs of poor perfusion or respiratory distress.

distinguish between a febrile child who may be unwell but is clinically stable (i.e., "non-toxic appearing") and a febrile child who requires immediate diagnostic and therapeutic intervention, usually for a serious bacterial infection such as meningitis or sepsis.

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viral synd causing seizures

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common viral infections (e.g., enterovirus, adenovirus) can cause significant fever in young children without any additional clinical signs or symptoms such as congestion, cough, diarrhea or rash
may be indistingusiable from occult bacteremia or UTI

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serious bacterial infections

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Occult bacteremia, meningitis and UTI

other SBI: bacterial gastroenteritis, pneumonia, septic arthritis and osteomyelitis.

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occult bacteremia

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febrile ages 3- 36 months w/o a discernible focus of infection
Streptococcus pneumoniae.
In the past, Hemophilus influenzae type B

Other than fever, no additional signs or symptoms of illness.
Undiagnosed, risk for the development of a more serious bacterial infection, such as meningitis or osteomyelitis, through bacterial seeding of these distant sites.

protein-polysaccharide conjugate pneumococcal vaccine (PCV-7), the rates of invasive pneumococcal infections have declined

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LP placement

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A line connecting the superior portions of the posterior iliac crests passes through the L3-4 or L4-5 interspaces.

22-gauge needle with a stylet is used to puncture the skin and then subarachnoid space. A "pop" is often felt as the needle punctures the dura (except in the neonatal age group where it is rarely felt).

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bacterial meningitis

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immunized children 2 months-12 years= S. pneumoniae or N. meningitidis, (invasive pneumococcal disease diminishing w routine vaccination)
younger infants= gram negatives such as E. coli and organisms like Group B Streptococcus (Strep agalactiae)

increasing lethargy and irritability, as well as signs of meningeal irritation (often referred to as nuchal rigidity or meningismus). Alternatively, non-specific findings, including fever (in 90-95% of cases), anorexia and poor feeding, symptoms of an upper respiratory infection, myalgias, and tachycardia may predominate.

tx high-dose intravenous antibiotics usually starting with a third-generation cephalosporin and vancomycin, total of 7-14 days.
given empirically as soon as the CSF culture is obtained (and in severe cases, even beforehand).

Complications: stroke, subdural effusions and the syndrome of inappropriate anti-diuretic hormone (SIADH) secretion.
unusual for treated meningitis to be fatal, morbidity such as developmental delays, seizures and hearing loss are known complications

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traumatic tap

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needle, in its path to the subarachnoid space, penetrates a blood vessel (often in the vascular epidural space)= interpretation of the true CSF cell count difficult.
15-20% of pediatric LPs. Although the presence of WBCs in CSF usually suggests infection, in a traumatic LP, WBCs are more likely to be from the blood contaminant. In addition, differentiating between a traumatic LP and a bloody CSF secondary to a CNS hemorrhage can also be difficult.

If their LP results cannot be interpreted, empiric parenteral antibiotics until the CSF culture is negative. A number of methods exist to estimate the true degree of CSF pleocytosis in a traumatic LP.
RBC / WBC ratio of approximately 250:1 is used. This can be generated by looking at the patient’s CBC and dividing the RBC count (in millions / microliter) by WBC (in thousands/ microliter). This is a very rough estimate and should only be used in the presence of experienced clinical judgment

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CSF results viral vs bacterial

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Viral meningitis is not generally associated with a drop in CSF glucose or elevation in CSF protein
(often caused by enteroviruses) will have a CSF pleocytosis, usually with a CSF WBC count ranging from 20 to 200 WBC/hpf. Lymphocytes are generally predominant, but some patients may have a predominance of CSF polymorphonuclear cells in the first 24 to 48 hours of their infection. Patients with meningoencephalitis due to herpes virus may also have an elevated RBC count in the CSF.

CSF hypoglycoracchia (decreased CSF glucose resulting in decreased CSF glucose/blood glucose ratio), elevated protein and an increase in WBCs with a predominance of polymorphonuclear cells. The gram stain may demonstrate organisms in the CSF.

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simple febrile seizure

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< 15 minutes occur once in a 24 hour period and are generalized seizures

simple febrile seizures have no long tern effects in terms of child development.

for epilepsy slightly increased above the 0.5-1% baseline population risk
Epilepsy is more common among those children with early, recurrent febrile seizures, especially if there is a family history of epilepsy. This is to be compared to essentially the same risk as the normal population in a child with one or two simple febrile seizures and no other features

acetominophen and ibuprofen medications are not helpful in preventing recurrence of febrile seizures

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complex febrile seizure

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prolonged (>15 minutes),
more than once in a 24 hour period,
focal seizures.

main issue with febrile seizures is the risk of recurrence.
first febrile seizure before age 12 months, the recurrence risk 50%.
after 12 months, recurrence risk 30%.

Children with complex febrile seizures, and those with abnormal development are at increased risk of epilepsy.

shouldn’t put anything in his mouth to keep him from biting his tongue, and don't restrain his movements during the seizure

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six anti-epileptic drugs for the potential treatment / prevention of simple febrile seizures.

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Phenobarbital: effective in preventing recurrence of simple febrile seizures when given regularly and the drug levels remain in therapeutic range. poor adherence to therapy and serious side effects in at least 20% of patients.

Primidone: effective in preventing recurrence of simple febrile seizures but also has a high side effect profile.

Valproic Acid: effective in preventing recurrence of simple febrile seizures but carries with it the dreaded side effect of hepatotoxicity.

Carbamazepine: not been shown effective in preventing febrile seizure recurrence.

Phenytoin: not been shown effective in preventing febrile seizure recurrence.

intermittent diazepam use (orally or rectally). S
oral diazepam, given at the start of the febrile illness, can be effective in preventing recurrent febrile seizures. seizure in many cases may be the first sign of a febrile illness, thus creating some limitations to this strategy. Despite this efficacy, the sedating side effects of diazepam, some of which may cloud the presentation of a serious CNS infection, led the committee to not recommend this.

Overall, anti-epileptic drugs are not recommended when one considers their side effects versus the fact that a febrile seizure recurrence is likely to be of little harm to the child.

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Roseola infantum (exanthem subitum – or sixth disease)

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common febrile rash illness of infants and young children under 2 years of age.
high fever (38.5 to 40.5 C) for 3 to 5 days in well-appearing child, followed by abrupt resolution of fever and development of a maculopapular rash.
some may have rhinorrhea.
unusual physical findings of bulging fontanelle= evaluation for meningitis (lumbar puncture).

Human herpesvirus-6 (HHV-6) = 20% to 30% of first febrile seizures in children.

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Fifth disease (or erythema infectiosum)

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Parvovirus B19) is characterized by a "slapped cheek" appearance and a reticular, lacy rash on the extremities.

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scarlet fever

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red lips, a strawberry tongue and a light-red sandpaper rash.

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rubeola (or measles)

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third stage of the disease with a maculopapular rash and fever combined.

rash preceded by prodromal stage of cough, coryza and conjunctivitis, as well as Koplik's spots on the buccal mucosa.