Prepared by :

Dr: Mayada Younis

Demonstrator of pediatric nursing

:Outlines
1. Introduction about convulsion

2. Definition of convulsion, seizure, epilepsy

3. Cause of convulsion

4. Febrile convulsion

5. Type of febrile convulsion

6. Management of febrile co1nvulsion

7. Classification of epileptic seizure

8. Treatment of epilepsy

9. Definition of status epilepticus

10. Treatment of status epilepticus

Introduction
Nearly 5% of all children suffer one or more
convulsions before 5 years of age; more than
50% of these are febrile convulsions.
A seizure:
is a sudden, paroxysmal disruption of the brain's
normal electrical activity accompanied by altered
consciousness and/or other neurological and behavioral
manifestations.

Seizures are not a disease in themselves. Instead, they

are a symptom of many different disorders that can
affect the brain.
Convulsion:

This means a motor seizure and consists of

abnormal involuntary muscular contractions which
may be:

• Sustained (tonic).

• Interrupted (clonic )

• Brief, jerk-like (myoclonic)

Epilepsy:
means recurrent seizures
Causes of convulsions:
I. Acute convulsions :

1. Febrile convulsions.

2. Intracranial infections: meningitis, encephalitis,

brain abscess.

3. Head injuries: birth trauma or later in life.

4. Intracranial hemorrhage due to birth or later trauma,

hemorrhagic diseases, or vascular malformations.
5. Brain anoxia:

• Prenatal or perinatal asphyxia.

• Sever bronchopulmonary disease.

• Congenital cyanotic heart disease

6. Metabolic: hypocalcemia, hypomagnesemia.

Hypoglycemia, hypernatremia, alkalosis, post-
acidosis.
7) Toxic agents as:

• Bacterial toxins from shigella, salmonalla, tetanus.

• Poisons: insecticides, lead

• Drugs: theophylline, corticosteroids, strychnine.

8 ) Intracranial neoplasm ( brain tumor ) .

9) Cerebrovascular:

•Embolism (sub-acute bacterial endocarditis).

•Thrombosis (cyanotic heart disease, dehydration).

• Hypertensive encephalopathy.
II. Chronic (recurrent ) convulsions i.e.
epilepsy:

Primary
secondary
Febrile Convulsions
Definition:
Febrile convulsions are tonic - clonic convulsions due to

rapid rise of body temperature caused by extra cranial

infections.
Epidemiology:
• They are the most common seizure disorder during
childhood.

• They are age dependent and are rare before 6 mo and

after 5 yr of age. The peak age of onset is approximately
14-18 mo of age .

• There is a strong family history of febrile convulsions

Types of febrile convulsions:

 Typical (primary, simple or benign).

 Atypical (secondary, complex or

complicated).
The typical fit is characterized by the
following :

✓Age from 6 mo - 6 yr .

✓Generalized tonic

✓Single during the same febrile illness.

✓A few seconds to 10 minutes in duration.

✓No neurological abnormalities in the child .

✓EEG is normal in between the attacks.

The atypical seizure is diagnosed if one of

the following is present :

• A seizure persisting more than 15 min.

• Repeated convulsions occur within the same day.

•A focal seizure.
The risk factors for the development of epilepsy
as a complication of febrile seizures include:
1 - Atypical febrile seizure.

2 - A positive family history of epilepsy.

3 - Initial febrile seizure prior to 6 mo or after 6 yr. of age

4 - Delayed developmental milestones.

5 - An abnormal neurological examination.

6 - Abnormal EEG in between the attacks.

Management of febrile convulsions:
-Aborting the attack of convulsion with diazepam 0.3
mg/kg slowly intravenously or rectally. This dose can be
repeated after 10 minutes if needed.

-Lowering the body temperature with tepid sponges (no ice

or alcohol) and antipyretics.

-Treating the cause of fever e.g. antibiotics for otitis media.

-Excluding intracranial infections by doing lumbar puncture

and CSF examination if any doubt exists.
Prophylactic therapy:

Diazepam has been shown to be effective in

preventing recurrences if given together with a
potent antipyretic immediately at the onset of
fever and continued until the patient has been a
febrile for 24 hours . Diazepam dosage is 0.3
mg/kg orally every 8 hours ( 1 mg/ kg/24 hr).
Epilepsy
Definition:
Recurrent seizures unrelated to fever or to an acute
cerebral insult (two or more unprovoked seizures occur
at an interval greater than 24 hr. apart are needed for the
diagnosis).
Etiology: Epilepsy is divided into two groups:
A- Idiopathic (primary):
• This is the main group and most of The patients (2/3
of cases) belong to it.

• It is called idiopathic because the etiology is

unknown The only important factor is heredity In more
than 90% of cases a positive family history of
epilepsy is present
B- Symptomatic (secondary):

•The minority of patients belongs to this group (1/3

of cases).

•It secondary occurs to a brain lesion.

The common causes are :
1. Congenital conditions : e.g. congenital
hydrocephalus, microcephaly, cerebral agenesis, and
vascular anomalies.

2. Post - infectious: following encephalitis , meningitis

and brain abscess.

3. Post traumatic.

4. Post hypoxic.
5. Post - hypoglycemic.

6. Post-toxic (e.g. after kernicterus).

7. Degenerative brain diseases.

8. Parasitic e.g. toxoplasmosis;

9. General causes : e.g. Tetany , Uremia

Classification of epileptic seizures
1)Partial ( focal ) seizures:
•Arise from a focal area in brain ( cortical or
subcortical ) .
•Give focal manifestations related to the area of origin .
•No loss of consciousness.
•May be associated with a preceding aura which
indicates a focal onset of the seizure (usually absent in
infants and young children).
• EEG: focal abnormalities.
Partial seizures may be:

• Simple partial (with no loss of consciousness).

• Complex partial (consciousness is impaired).

• Partial seizures with secondary generalization.

Partial with secondary generalization
•Arise from focal area.
•Starts with localized manifestations
followed by secondary spread to the other
side and loss of consciousness
•EEG: focal abnormalities with secondary
generalization.
2- Generalized seizures

•Give generalized manifestations (both

cerebral hemispheres are involved)

•Consciousness is lost

• EEG: generalized abnormalities

Generalized seizures may be:

*Tonic - clonic (grand mal)

*Absence (petit mal)

*Myoclonic

*Atonic (a kinetic)
3- Unclassified seizures
The best example is subtle neonatal
seizures
Generalized Tonic - Clonic Seizures (Grand
mal epilepsy)

Three clinical stages may be detected to occur

successfully:

1) Pre convulsive stage: (occurs in few cases):

As pallor, irritability or behavioral changes. Parents

may be familiar with these changes.
2 ) Convulsive stage :
-The attack usually occurs without
warning
-The consciousness is suddenly lost and
the child falls to the ground .
• Tonic phase: during this phase there is
sustained contraction of the muscles,
apnea, cyanosis and tongue biting.
Clonic phase:
during this phase there is repetitive contraction
of muscles, frothing at the mouth, and at the end
of the attack relaxation of sphincters occur
leading to bedwetting and defecation.
The convulsive stage lasts from one to several
minutes.
3) Post - ictal stage:
After the attack, the patient falls asleep or suffers
from headache, depression and confusion and on
rising, he is completely normal.
Precipitating factors of generalized tonic -
clonic seizures in children:
1) Excessive fatigue.
2) Lack of sleep.
3) Infectious illnesses and fever
4) Emotional stress.
5) Drugs as theophylline, psychotropic drugs,
methylphenidate .
 6) Sensory stimuli such as flashing lights, visual

patterns, sounds including music and startling by noise

or touch.

7) Sudden withdrawal of AED .

Absence (Petit Mal)
1 - Usually in children more than five years old,
more in females.

2 - There is a sudden loss of voluntary motor

activity.

3 - The child loses consciousness but doesn't lose

postural tone (does not fall)

4 - There is a blank star and rapid eye blinking).

5 - This lasts around 30 seconds and then the child
resumes his/her pre seizure activity

6 - No postictal confusion

7 - The attack can be induced by hyperventilation

8 - Has a characteristic EEG pattern ( 3 per second

spike and wave pattern )

9 - May be associated with poor school performance

10 - Etiology: idiopathic (genetic)

Myoclonic Seizures
1 - The attack is characterized by short involuntary
muscle contractions usually of a localized group of
muscles

2 - Upper limbs are more commonly affected

3 - More frequent in the morning after awakening

4 - Loss of consciousness may not be noticed due to

very short duration.
Diagnosis of epilepsy:
This is essentially on a clinical basis, through history
from the parents and observation by the pediatrician.
•Investigation of the suspected cause e.g.
metabolic studies, CSF examination, MRI.
•EEG: if positive is confirmatory. It may be normal
in more than 30% of epileptic children. A normal
EEG does not exclude epilepsy .
Treatment of epilepsy

I. General treatment:

• •An epileptic child should should, as far as possible,

lives a normal lives and attend school.

• The parents should avoid situations of obvious

dangers e.g. swimming and working at a height

• The parents should avoid the precipitating factors

Moderate exercise is desirable but violent ones may

precipitate fits.
II. During the attack of convulsion :
1- First aid :

-Put the patient in semi prone position with the head

turned to one side

-suctioning and cleaning of the airways

-Do not thrust a tongue depressor or spoon handle into

clenched teeth .

- Do not try to restrain the patient.

2- Give oxygen if the patient is cyanosed.

3- Correct the cause if it is evident (e.g. glucose in

hypoglycemia and calcium in cases of tetany).

4- If the cause is not evident or not readily

correctable, give diazepam, 0.3 mg/kg slowly
intravenously. This dose can be repeated after 10
minutes.
III.Long term therapy with AEDs:
- Indications:
1. The patient is neurologically abnormal
2. The presence of a focal brain lesion
3. Positive family history of epilepsy
4. Abnormal EEG
-Rules:
• Only one drug, known to be effective for the seizure
type, should be used at a small dose that is increased
gradually at intervals of two weeks till the fit is
controlled or the maximum dose is reached.

• If the drug is ineffective, start a 2nd one in a similar

way, and once seizures are controlled, start gradual
withdrawal from the first one.
-Treatment is continued for at least 2 - seizure free

years.
- Follow up:
- Because most serious adverse effects of
anticonvulsant drugs develop during the
initial 2-3 mo. of therapy, screening of
complete blood count and liver function
studies should be done every month for the
first 3 months. Subsequently, routine blood
tests are ordered only when clinically
indicated.
- Routine Serum monitoring of
anticonvulsant levels.
Most common anti-convulsant drug:

• Valproate: is a broad spectrum AED.

• Carbamazepine: is more preferable in partial

seizures.

• Phenobarbital and phenytoin are less frequently

used now due to their effects on cognition.

Status Epilepticus ( SE)
Definition:

a continuous convulsion lasting greater than 30

min, or

The recurrence of serial convulsions between

which there is no return of consciousness.

Etiology:

- A prolonged febrile convulsion in a child < 3 yr old , is

the most common cause

- Rapid withdrawal of AED at any age

- Idiopathic SE: a develop seizures in the absence of an

underlying CNS lesion or insult

- Symptomatic SE: a seizure occurs in association with

a longstanding neurological disorder or a metabolic
abnormality
Treatment:

A- Airway patency: by suctioning, semi prone position

± put airway tube

B- Breathing: should be adequate

C - Circulation: should be insured

D - Drugs: all drugs should be given IV.

AEDs are tried in the following order: Diazepam (0.3mg

/ kg ) is used initially.
 -Phenytoin infusion: IV loading dose 20 mg/kg slowly
over 30 min, divided doses. Followed 12 hours later by
maintenance dose of 5-8 mg/kg/day in two

-Phenobarbital: IV loading dose 20 mg/kg slowly over 30

min, followed 12 hours later by maintenance dose of 3-5
mg/kg/day in two divided doses.

-Diazepam IV infusion 2mg/hr.

-General anesthesia and assisted ventilation is given if the

above-mentioned measures fail.