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 | |||||||||||||||||||||||||||||
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