Seizure: transient occurrence of signs/symptoms

resulting from abnormal excessive or synchronous

neuronal activity in the brain
Seizure: focal (partial) and generalized
Epilepsy: brain disorder in which an individual
endures predisposition to generate seizures.

i.e. : 1 unprovoked epileptic seizure + (second similar

seizure OR EEG and clinical info convincingly demonstrate

the predisposition)
Epidemiologic purpose: 2 unprovoked seizure within >
24 hr

4-10% children has at least 1 seizure before

16 y0.
Lifetime incidence of epilepsy: 3%
30% of those who have 1st febrile seizure
epilepsy

Seizure Medical Emergency!

Airway, Breathing, Circulation
Vital signs (temperature, blood pressure, heart

rate, respiratory rate)

Blood glucose
Serum electrolytes

Potentially life-threatening: meningitis,

sepsis, head trauma, drug abuse,
intoxication.

1.
2.
3.
4.
5.
6.
7.
8.

Focal or generalized?
Duration of seizure
State of
consciousness
Presence of aura
Posture
Cyanosis
Loss of sphincter
control
Postictal state

Physical Exam:
Head circumference,

anthropometric studies.
General examination
Neurologic examination

Seizures that occur between age of 6-60 mo

with a temperature > 38oC in the absence of
CNS infection, metabolic imbalance or
history of afebrile seizures.
Type: simple and complex.
Risk factors of subsequent epilepsy:
neurodevelopmental abnormalities (33%),
focal complex febrile seizure (29%), familial
history of epilepsy (18%), fever < 1 hr (11%),
recurrent febrile seizure (4%)

Lumbar puncture?
1st FS in children < 12 mo
Children with seizure

between 12-18 mo
> 18 mo with clinical
suspicion only

EEG?
After 2 wks passed the

seizure

Blood studies
Based on indications

only!
CBC, serum electrolytes,
RBG, Ca, Mg, P

Neuroimaging
Not indicated in first

febrile seizure

Counselling on RR of recurrence of FS and

epilepsy and how to handle the seizure
Acute treatment of seizure with diazepam,
lorazepam, or midazolam accordingly
Intermittent oral diazepam: 0.33 mg/kg q8h,
during fever
Antipyretic agents to reduce fever
What about other AEDs? Any indications?

DRUG
Lorazepam

ROUTE
Intravenous
Intranasal
Intravenous

Midazolam

Diazepam

Phosphenytoin

Intramuscular
Intranasal
Buccal
Intravenous
Rectal
Intravenous
Intramuscular

Paraldehyde

Rectal

Phenobarbital
Pentobarbital coma

Propofol
Thiopental
Valproate

Intravenous

DOSAGE (mg/kg)
0.05-0.1
0.1
0.2 loading
0.08-0.23/hr
maintenance
0.1-0.5
0.2-0.3
0.2-0.5
0.2-0.5
2-5 yr: 0.5
6-11 yr: 0.3
12 yr: 0.2
15-20 PE, then 36/24 hr
0.2 mL/kg
0.4 mL/kg + same
volume of olive oil
5-20
13.0, then 1-5/hr
1 (bolus), then 115/hr (infusion)
5/1st hour, then 12/hr
Loading: 25, then
30-60/24 hr

AGE

Neonate

GENERALIZED
PAROXYSMS
Apnea
Hyperekplexia
Jitteriness
Paroxysmal
extreme pain
disorder

ABNORMAL
OCULOMOTOR
MOVEMENTS
ABNORMALITIES
AND POSTURES

Jitteriness
Paroxysmal
dystonic
choreoathetosis

Paroxysmal tonic
up gaze
Alternating
hemiplegia of
childhood

SLEEP
DISORDERS

Benign neonatal
sleep myoclonus
Sleep transition
disorders

AGE
Infants

GENERALIZED
PAROXYSMS

ABNORMAL
OCULOMOTOR
MOVEMENTS
ABNORMALITIES
AND POSTURES

Hyperekplexia
Jitteriness
Reflex anoxic
Sandifer
seizures
Paroxysmal
Breath-holding
dystonic
spells
choreoathetosis
Benign paroxysmal Benign myoclonus
vertigo
of early infancy
Pathologic startle Shuddering
Paroxysmal
attacks
extreme pain
Benign
disorder
paroxysmal
torticollis
Psychological
disorders
Alternating
hemiplegia of
childhood
Jactatio capitis
head banging
Drug reactions

Paroxysmal tonic
upgaze
Oculomotor
apraxia
Spasmus nutans
Opsoclonus
myoclonus
syndrome

SLEEP
DISORDERS
Non-REM partial
arousal disorders
REM sleep
disorders
Narcolepsy
Sleep transition
disorders
(somnambulism,
somniloquy)

AGE
Children and
adolescents

ABNORMAL
OCULOMOTOR
SLEEP
MOVEMENTS
ABNORMALITIES
DISORDERS
AND POSTURES
Benign
Tics
Daydreaming
Non-REM partial
paroxysmal
Tremor
Drug reactions
arousal disorders
vertigo
Paroxysmal
REM sleep
Pathologic startle dyskinesias
disorders
Compulsive
Benign paroxysmal
Narcolepsy
valsalva
torticollis
Sleep transition
Alternating
Episodic ataxia
disorders
hemiplegia of
Psychologic
(somnambulism,
childhood
disorders including
somniloquy)
Familial hemiplegic Munchausen
Sleep myoclonus
migraine
syndrome by
Restless legs
Syncope (Long QT, proxy, malingering
syndrome
vasovagal,
Masturbation
vagovagal,
Jactatio capitis
orthostatic,
(head banging)
migraine-induced) Episodic rage
Psychogenic
Drug reactions
seizures
Cataplexy
Transient global
amnesia
Hyperventilation
spells
GENERALIZED
PAROXYSMS

A 4-yr-old boy is evaluated for his first generalized tonic-clonic seizure,

which lasted 10 min. There is no history of illness or fever, and findings
on examination an hour after the seizure are completely normal. The
most appropriate management is:

1.

Begin therapy with CBZ

Order an EEG
Order a CT Scan of the brain
Order an MRI Study of the brain
Order psychometric testing

A 15-mo-old girl is evaluated for a 10-min-long generalized seizure

associated with a temperature of 40oC. Which of the following factors
in the history is most likely to increase the risk of future seizures?

2.

APGAR Score of 3 at 5 minutes

Family history of epilepsy
Clinical evidence of roseola
Female gender
Presence of 2 caf-au-lait spots

A 3-yr-old boy is being evaluated after an episode at home during

which he lost consciousness for 5 min; he was brought to the
emergency department an hour later. On examination, which of the
following factors is most helpful in distinguishing whether this episode
was a seizure or syncope?

3.

Family history
Temperature
Blood pressure
Level of consciousness
Size of pupils

4.

Please draw the algorithm of acute treatment in children with seizures.

5.

Please explain how to prepare the administration of phenobarbital as if

you were discussing the drug with the nurses.

Homework:
Epilepsy
Types of AEDs and their

indications
CNS infections and their
treatments
Congenital anomalies of
CNS with seizure
presentation and their
treatments