Convulsions

(Seizures and Epilepsy)

Mr. Dipti Sorte
 Aims & Objectives
• At the end of class the students will be able to:
1. Define Seizures & Epilepsy.
2. Classify Seizures & Epilepsy.
3. Describe mechanisms of Seizures & Epilepsy.
4. Explain Genetical interference.
5. Describe etiology.
6. Explain pharmacological interventions.
7. List diagnostic features.
8. Describe treatment of Seizures & Epilepsy.
9. Discuss nursing mangement of Seizures & Epilepsy
 Define Seizures and Epilepsy.
• Seizures, is a paroxysmal involuntary disturbance of
brain function that manifest as impairment of
consciousness, motor or sensory activity, autonomic
or behavior disturbances due to abnormal electrical
activity of brain.
• Epilepsy is When two or more unprovoked seizures
occur at an interval greater than 24 hours apart.
 Classification of Epileptic Seizures

A. Partial Seizures:
1. Simple partial seizures – Consciousness maintained.
• Motor.
• Sensory.
• Autonomic.
• Psychic.
2. Complex partial seizures – Loss of consciousness
 contd
B. Generalized Seizures:
1. Absence seizures. (Petit mal Seizures)
• Typical.
• Atypical.
2. Generalized seizures.
• Generalized tonic clonic seizures.
• Clonic seizures.
• Atonic.
• Myoclonic.
• Infantile spasm.
 Unclassified Seizures
• A seizure may be unclassified due to inadequate
information to allow it to be placed in the focal,
generalized or unknown onset categories. This
may occur if it was not witnessed at onset, and if
results of investigations (such as EEG and
imaging) are not yet available
 Neonatal epileptic Seizures
• The neonatal period is the most vulnerable
period of life for developing seizures. Neonatal
epileptic seizures often constitute a neurological
emergency demanding urgent diagnosis and
management. Neonatal seizures are paroxysmal,
repetitive, and stereotyped events. They are
usually clinically subtle.
Mechanism of seizures
• Seizures arises from a focus of neuronal cell death. Theses
areas develops hyper excitability synapses.
• Seizure discharge depends upon excitatory glutaminergic
synapses.
• Neuronal excitation may be by amino acids
neurotransmitter like glutamate and aspartate.
• Stimulation of amygdala by kindling may produce seizures.
• Underdeveloped brain is more susceptible to specific
seizures.
• Genetic factors.
 Chromosomal abnormality
• 20q 8q – Benign neonatal convulsions.
• 6p – Juvenile myoclonic epilepsy.
• 21q 22.3 – Progressive myoclonic epilepsy.
• Substantia nigra has role in regulation and
dissemination of seizures
 B. Metabolic.
Etiology • Hypoglycemia.
• Hypocalcemia.
A. Perinatal • Hypomagnesemia.
conditions:
• Hyponatremia.
• Cerebral malformation.
• Reye’ Syndrome.
• Intrauterine infections.
• Porphyria.
• Hypoxic ischemia.
• Pyridoxine
• Hemorrhage. dependency/deficiency.
• Trauma. • Hypernatremia.
• Hyperbilirubinemia.
 C. Intracranial infections. F. Systemic disorders:
• Meningitis. • Vasculitis.
• Encephalitis. • SLE.
• Brain abscess. • Hypertensive encephalopathy.
D. Poisoning. • Renal failure.
• Lead, cocaine. • Hepatic encephalopathy.
• Drugs and drug withdrawal. G. Others:
E. Neuro – cutaneous • Trauma.
syndromes. • Tumor.
• Tuberculous sclerosis. • Febrile seizures.
• Neurofibromatosis. • Idiopathic.
• Sturge – weber syndrome. • Familial.
• Degenerative disorders.
Treatment: Anticonvalscents drugs are:
S. No. Name of the Drugs Doses
1 Carbamazepine 10 – 40mg /kg/day
2 Phenobarbitone 3 – 8 mg /kg/day
3 Phenytoin 3 – 8 mg /kg/day
4 Valproic acid 10 – 60mg /kg/day.
5 Clonazepam 0.05 – 0.2 mg/kg/day.
6 Clobazam 0.1 – 1mg /kg/day
7 Ethosuximide 20mg/kg/day.
8 Paraldehyde 0.1 to 0.2ml/kg/dose deep IM.
9 Gabapentin 15 - 45mg /kg/day.
10 Lamotrigine 2 – 10mg /kg/day.
11 Nitrazepam 0.2mg/kg/day.
12 Tiagapine 6 mg TDS
13 Vigabatrin 30 – 100mg/kg/day, 20 – 100mg/kg.
14 Primidone 10 -25mg /kg/day.
15 ACTH 20 – 40 Units IM/day.
Evaluation (Diagnostic measures) • Urine toxicology.
• CBC. • Fundus.
• Blood chemistry. • CSF Examinations.
• EEG.
• Glucose.
• Brain Imaging.
• Ca⁺⁺⁺, Na⁺, K⁺, Cl⁺.
• CT.
• Bicarbonate.
• MRI.
• Urea Nitrogen.
• ECG.
• Creatinine.
• Mg⁺ 2

• Blood toxicology.
 Treatment of Epilepsy
• Medical treatment.
• Preferably one drug should be used depending upon type of seizures
(Clinically and EEG based.
• Dosage of drug can be increased up to maximum dose.
• If seizures are not controlled second drug may be used.
• Duration of treatment – seizures free period 2 – 3 yrs, then tapper the dose.
• Periodic check up 3 monthly for side effects of drugs.
• Life long treatment for juvenile myoclonic epilepsy.
• Therapeutic drug monitoring.
 Surgical treatment
Indications:
• Intractable seizures.
• Focal seizures.
• Resection of epileptogenic foci.
Ketogenic diet
 • Counselling of parents.
• First aid measures.
• Regularity of Drugs.
• Child should avoid swimming, fires, machine work, swing.
• Child should have identification card with him whenever he
is out of home.
• Child should not be permitted to go to terrace alone.
• He should avoid playing with crackers.
• Sleep should be complete and in proper time.
Status Epilepticus
•Definition: Continuous convulsion
lasting longer than 30 mins. or
occurrence of serial convulsions
between which there is no return of
consciousness or brought to hospital
seizing.
 • Classification:
• Generalized.
• Tonic Clonic.
• Absence.
• Partial.
• Simple.
• Complex.
• Secondary generalization.
• Neonatal status.
 • Etiological classification: There are sub-
major types
• Prolonged febrile seizures.
• Idiopathic status epilepticus.
• Symptomatic status epilepticus.
 Predisposing factors & • Inborn errors of metabolism.
Causes: • Electrolyte imbalance.
• Sudden withdrawals of Anti- • Hypocalcemia &
convalescents.
Hypoglycemia.
• Irregular Anticonvalscents therapy.
• Drug intoxication.
• Sleep deprivation.
• Encephalitis. • Reyes syndrome.
• Meningitis. • Lead intoxication.
• Congenital malformation of brain. • Extreme hyperpyrexia.
• Lissencephaly. • Brain tumor – especially frontal
• Schizencephaly. lobe.
 Management: There are five Principles of
Management:
• Stabilize patient.
• Rapid control of seizures.
• Supportive treatment.
• Search for cause.
• Maintenance therapy.
 Stepwise Approach
• Step 1: ABC (Airway, Breathing, Circulation).
Suction, O2, Ventilation, Circulation IV line. One I/V
line for collecting blood sample, Second, I/V line for
therapy. Investigation required such as Blood sugar,
Ca⁺, Mg⁺2 Electrolytes. If hypoglycemic then 25%
dextrose 2ml/kg I/V.
• Step 2: To modify as per IAP Guidelines:
• Diazepam (Dose – 0.3mg/kg/I.V.)
• Or
• Lorazepam (Dose – 0.05-0.1mg/kg/I.V.) can be repeated
after 10mins. If seizures not controlled
• Phenytoin or fosphenytoin (Dose – 15-20 mg/kg/I.V. in
saline)
• Further dose of phenytoin 10mg if seizures not controlled.
• Pyridoxine B 6 (Dose – 200mg I.V. Stat)
• Step 3: Anesthesia Phentobarbitol.
Febrile convulsions
•Definition: Seizures precipitated by rapid
rise of fever in the age group of 6months to
6yrs. (Most commen between the age of 14
and 18 months)
 • Types: (Two types) B. Atypical febrile convulsions
A. Typical febrile convulsions. • Age < 6months or >6yrs.
• Generalized seizures. • Duration more than >15 mins.
• Duration <15mins. • Focal convulsions.
• Occurs only once in 24 hours. • <1 seizure in 24 hours.
• Family history may be there. • Neurologic deficit before or after
• Normal EEG after 7days. attack.
• No CNS infections. • Abnormal EEG 7 days later
• CSF is normal.
• No Neurological deficit.
• Immediate recovery from
unconsciousness
 • Treatment:
• Control fever by:
• Tepid sponging.
• Paracetamol
• Control convulsion by:
• Lorazepam/Midazolam IM/ Nasal spray.
• Treat the cause of fever.
• Prophylaxis:
• Short term prophylaxis: Anticonvalscents should be used during the period of fever.
• Long term prophylaxis:
• Indications:
• Atypical febrile convulsions.
• Fever with neurological diseases like C.P, M.R.
• Drugs:
• Sodium valproate – Dose 3-5mg/kg/day.
• Phenobarbitone – Dose 3-5mg/kg/day.
 Nursing management
• An important nursing responsibility to observe the
seizure episode and accurately document the events.
Any alteration in behavior preceding the seizure and
the characteristics of the episode such as sensory
hallucinatory phenomena (eg. Aura) motor effects (eg.
eye movement, muscular contractions.) alteration in
consciousness and postictal state, are noted and
recorded. The nurse should describe only what is
observed rater than trying to label seizures type Note
the duration of the seizures with start and stops time.
Summary
• If a baby or child has a seizure during a high
fever, cool the child slowly with lukewarm water.
DO NOT place the child in a cold bath. Call your
child's health care provider and ask what you
should do next. Also, ask if it is OK to give the
child acetaminophen (Tylenol) once they are
awake
 References
• https://www.google.com/search?
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WIQARgAMgIIADICCAAyBggAEBYQHjIGCAAQFhAeMgYIABAWEB46BA
gAEEdQjOcDWIznA2DR-
wNoAHABeACAAd8BiAHfAZIBAzItMZgBAKABAqABAaoBB2d3cy13aXo&
sclient=psy-ab
• https://www.google.com/search?sxsrf=ALeKk03haPOkDP8RvvnjsIV3G-
Daa8v_mA
%3A1589766113159&source=hp&ei=4efBXt6fB5_gz7sPipKwgAc&q=neonatal+
epileptic+seizures&oq=Neonatal+epileptic+Seizures&gs_lcp=CgZwc3ktYWIQA
RgAMgQIABAeOgcIIxDqAhAnUPEiWM1LYItdaAFwAHgAgAG0AogB_wqSA
QcwLjEuNC4xmAEAoAECoAEBqgEHZ3dzLXdperABCg&sclient=psy-ab
Thank you