Seizures and Status Epilepticus



Seizures and Status Epilepticus


Khalid Al-Ansari



Introduction



  • Seizures are a common presentation to the emergency department


  • 4-10% of children have at least one seizure during childhood


  • Majority of seizures during childhood are febrile seizures


  • Status epilepticus: a seizure or series of seizures lasting for ≥30 minutes without return to full consciousness


  • 12% of children present with status epilepticus as their first seizure


International Classification of Seizures


Generalized



  • Tonic-clonic: most common type in children


  • Tonic


  • Clonic


  • Myoclonic


  • Atonic


  • Absence


Partial



  • Partial simple: no change in level of consciousness


  • Partial complex


  • Secondarily generalized


Febrile Seizure



  • Benign seizures


  • Occur in up to 5% of children


  • Elevated body temperature lowers threshold for seizures



  • Typical age: 6 months to 6 years


  • Simple seizures: generalized, duration < 15 minutes, one episode in 24 hrs, developmentally normal child, no residual neurologic deficits


  • Usually associated with viral illness


  • Child often looks well in emergency department: can be discharged with reassurance and education for future episodes


  • Clinical signs of meningitis may be absent in children < 12-18 months of age


  • Consider septic workup including lumbar puncture in young child < 1 year, unwell appearance, or complex presentation (prolonged > 15 minutes, focal presentation, > 1 seizure in 24 hrs)


  • Recurrence rate 30%


  • Risk of epilepsy 2-4%


Afebrile Seizure



  • First episode of afebrile seizure: consider workup including sodium, calcium, glucose


  • Consider magnesium, ammonia, liver function tests, toxicology as indicated by history and examination


  • CT head is rarely required for first afebrile seizure with nonfocal presentation unless prolonged or focal seizure, focal deficits, sick appearance, history of trauma or VP shunt, signs of increased ICP


  • Outpatient CT head may be useful for identifying structural anomalies


  • EEG should be arranged as an outpatient: usually abnormal in immediate postictal period


  • Known seizure disorder: most common reason for recurrent seizures is subtherapeutic levels of anticonvulsants:



    • May be due to inadequate dose, noncompliance, or intercurrent illness


    • Measure anticonvulsant level in blood



Status Epilepticus



  • 80% of status epilepticus have a focal onset and then secondarily generalize


  • Mortality depends on underlying etiology


  • Increased risk of subsequent epilepsy, cognitive neurological deficit, and movement disorders


  • Refractory status epilepticus:



    • Sustained seizures that do not respond to medication and persist > 60 minutes


    • Requires ICU admission and continuous EEG monitoring


    • Duration correlates directly with increased mortality








Table 47.1 Etiology by Age






































NEONATES*


CHILDREN


ADOLESCENTS


Hypoxic ischemic encephalopathy


Febrile seizure


Epilepsy


Infection


Infection


Infection


Stroke


Metabolic disturbance


Drugs


Intraventricular hemorrhage


Epilepsy


Trauma


Trauma


Trauma


Tumor


Inborn error of metabolism


Tumor


Stroke


Congenital malformation


Congenital malformation


Pyridoxine deficiency


* See Ch. 11, Newborn Emergencies.

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Seizures and Status Epilepticus

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