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Home , Postictal state

1/15/2020

Disclosures

Relevant Financial Relationship(s) None Pediatric Off Label Usage James Miles, MD None NDAFP Family Medicine Update January 22, 2020

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Learning Objectives Definitions

• Review the key concepts of pediatric seizures. • : clinical expression of abnormal, • Appreciate how to evaluate a child with spells excessive, synchronous discharges of neurons concerning for seizure. residing primarily in the cerebral cortex. • Highlight the different types of treatment of • : at least two unprovoked seizures pediatric seizures. occurring more than 24 hours apart. • Be able to identify some common pediatric • Provoked seizure : secondary cause such as seizure disorders. hyponatremia, hypocalcemia, high fever, toxic • Differentiate between seizures and nonepileptic exposure, intracranial bleeding, or bacterial spells. meningitis.

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Epidemiology Seizure Semiology

• 0.5-1% kids will experience at least one • Generalized seizures afebrile seizure by adolescence – Tonic/Tonic-Clonic • 3-5% kids at least one – Absence – 3-6% will develop epilepsy – Myoclonic • 3.6% experiencing at least one seizure in an • Focal seizures 80-year lifespan – Tonic/Tonic-Clonic • Risk of having a seizure is greatest in infancy – Temporal lobe and after age 60 – Secondary generalization • M>F, higher in lower socioeconomic groups

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Pediatric Etiology Adult Etiology

• Genetic • Ischemic or hemorrhagic • Structural: injury, neurodevelopment • Traumatic head injury and bleeds • Metabolic: fever, hypocalcemia, hyponatremia • tumors and vascular malformation • Infectious/Immune: meningitis, encephalitis, • Neurodegenerative dementia sepsis, autoimmune • Infection (brain abscess) • Unknown: genetic? • Metabolic disturbance • Substance

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Metabolic Disturbances Substances

• Hypoglycemia and hyperglycemia • Withdrawal – Diabetic patients – Alcohol and • Hyponatremia: AMS, high risk of mortality • Drug intoxication, poisoning, overdose • Hypocalcemia: rare, more common in neonates – Thyroid/parathyroid surgery, renal failure, – Cocaine and amphetamines hypoparathyroidism, pancreatitis • Prescription medications • Hypomagnesemia: agitation, , myclonus, tetany • Uremia: renal failure/dialysis patients, myoclonic seizures • Hyperthyroidism

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Medications Medications

Category Examples Category Examples Analgesics (eg, meperidine, tramadol) Immunosuppressants Azathioprine, cyclosporine, Anticancer drugs Busulfan, chlorambucil,cytarabine, mycophenolate, tacrolimus doxorubicin, etoposide, fluorouracil, Psychiatric medications Antipsychotics (clozapine), atomoxetine, interferon alfa, methotrexate, bupropion, buspirone, lithium, MAO mitoxantrone, nelarabine, platinum-based inhibitors, SSRIs, SNRIs, serotonin drux (eg, cisplatin), vinblastine, vincristine modulators, TCAs Antimicrobials Carbapenems (eg, imipenem), Pulmonary medications Aminophylline, theophylline cephalosporins (4 gen), flouroquinolones Stimulants Amphetamines, methylphenidate (eg, ciprofloxacin), isoniazid, penicillins Sympathomimetics and decongestants Anorexients (including nonprescription Hypoglycemic agents Any antidiabetic Tx that can cause diet aids), phenylephrine, pseudoephrine hypoglycemia

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Evaluating Pediatric Seizures History

• Events prior to spell – Illness or injury? – Substance or Medication? • Characterization of spell – What did it look like? Video? – First time? Frequency? Duration? • Events after spell – Confusion or drowsiness?

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History Physical Exam

• Past medical history • Observation – Pregnancy, labor and delivery, neonatal period • Mental status – Growth and development • Neurologic exam – Surgeries or hospitalizations – Focal deficits – Chronic illnesses – Upper motor neuron signs Medications – • Hyperventilation – Education/Academic performance – Social History – Family History

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Diagnostics Treatment

• Physical exam • Daily preventative medications – Spell during exam • Rescue medications – Hyperventilation – Diazepam rectal or buccal • EEG – Clonazepam • Labs • Ketogenic diet – Serum and urine • Vagal nerve stimulator – CSF • • CT head/MRI brain

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Daily Preventative Medications Levetiracetam (Keppra)

• Levetiracetam • MOA: Binds SV2A • Ethosuximide (absence seizures) • Dosing: 10 mg/kg divided BID x 1 week, then • Oxcarbazepine (focal seizures) 20 mg/kg divided BID • Clonazepam (acute illness?) – 20-100 mg/kg/day • Infantile spasms: ACTH, Vigabatrin – May switch to TID dosing in young kids • Other: Brivaracetam, Carbamazepine, Clobazam, • Adverse effects: Behavioral in 10% kids Felbamate, Gabapentin, Lacosamide (focal), Lamotrigine , Phenobarbital, Rufinamide, • Monitoring: Drug level sometimes Topiramate , Valproate , Zonisamide

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Ethosuximide (Zarontin) Pediatric Seizure Disorders

• MOA: Blocks T-type calcium channels • Dosing: Start 10 mg/kg/day divided BID – 20-40 mg/kg/day • Adverse effects: – Common: GI upset, drowsiness, hiccups – Serious: Stevens-Johnson syndrome • Monitoring: – Drug levels if necessary – CBC, LFTs, urinalysis every 6 months

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18 mo F with febrile seizures Simple vs. Complex Febrile Seizures

• Hx global developmental delay since birth Simple Complex • 3 seizures with fever requiring multiple seizure • 6 months to 6 years • 6 months to 6 years rescue medications, 2 of them lasting hours • GTCS, atonic, tonic • Focal seizures • < 15 minutes, self-resolves • > 15 minutes, requires Tx • Often GTCS, may have focal jerking of the RUE • Don’t recur w/in 24 hrs • Recurrence w/in 24 hrs at the start • Return to baseline quicker • Longer postictal phase • Family history of epilepsy • Normal development • Developmental delay • Family Hx febrile seizures • Family Hx epilepsy

Febrile : > 30 minutes

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Absence Epilepsy

• Most common in school-aged kids • Most common in adolescence • Behavioral arrest and blank stare • Preceded by auras • Behavioral arrest, eye deviation, oral automatisms, • Duration: 10-15 seconds posturing of arms • May see eyes going upward, eyelid fluttering, • Duration: 30-60 seconds oral automatisms, finger/hand movements • Postictal period typical • No • Dx: EEG and MRI brain – Hippocampal sclerosis: Hx febrile seizures common, often • Dx: Hyperventilation and EEG complex • Tx: Ethosuximide • Tx: Surgery can be curative

https://www.youtube.com/watch?v=H3iLQi6wt94

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Behavioral Staring Spells Infantile Spasms

• “Extreme form of daydreaming” • Onset 3-7 months, after • Blank staring, may have random movements 18 months rare • Distractibility • Developmental plateau and regression • Can last much longer • EEG: • More often seen when bored or inactive • Tx: ACTH and Vigabatrin – Watching TV, sitting in class • ADHD , dev delay, autism • Dx: Physical exam, EEG

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Nonepileptic Paroxysmal Disorders Psychogenic Nonepileptic Spells

• Stress response • No EEG correlate • Rarely under the control of the child – Not malingering, seeking, “faking it” • Do not respond to anti-seizure medications

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Non-epileptic behavioral event

• Arrhythmic, asynchronous shaking of limbs • Neurocardiogenic (aka vasovagal) • No-no head shaking – Positional • Pelvic thrusting – Often triggered by stimulus (heat, blood, etc) • Intermittent responsiveness – Lightheaded, visual blurriness, “blacks out” or “curtain falls”, tunnel vision • Forced eye closure – Fall limply • Prolonged without post-ictal confusion – Regain consciousness shortly after falling • Do not arise out of sleep – May be disoriented after, but not confused – Can have

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Breath-Holding Spells Resources

• 6 months to 6 years • . https://epilepsy.com • Kotagal S. Parasomnias in childhood. Sleep Medicine Reviews. • Pathogenesis unclear 2009; 13: 157-168. – Autonomic nervous system dysfunction? • Mayo Clinic. https://mayoclinic.org. – Iron deficiency anemia more prevalent • Mayo Clinic Professional Photography and Videography. th • Fam Hx in 20-35% patients • Pina-Garza JE. Fenichel’s Clinical Pediatric Neurology . 7 ed. • Radiopaedia. https://radiopaedia.org. • Cyanotic and Pallid • Swaiman KF et al. Swaiman’s Pediatric Neurology: Principles • Dx: Clinical +/- EKG and Practice . 5 th ed. • UpToDate. https://uptodate.com. • Tx: Education, iron supp https://www.youtube.com/watch?v=e0640GTjScQ 33 34

Questions?

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