Seizures

Seizures (Video) are a pathological condition that manifests itself in involuntary muscle contractions that occur suddenly in the form of paroxysms and are a clinical manifestation of damage to the central nervous system (CNS). Seizures can occur with or without loss of consciousness.

Ваш браузер не поддерживает JWPlayer

Video. Seizures in children

The main causes of seizures in children:

hypoxia, ischemic brain damage;
intracranial hemorrhage;
metabolic disorders (hypoglycemia, hypocalcemia, hyper- or hyponatremia, hypomagnesemia, hyperbilirubinemia, hyperammonemia, acidosis);
infections (meningitis, encephalitis, sepsis);
genetic and congenital brain malformations;
withdrawal of medication if the mother is addicted to opiates, alcohol, sedatives and antidepressants;
congenital abnormalities of metabolism (phenylketonuria, acidemia, galactosemia, etc.);
other causes (hypothermia or hyperthermia, familial seizures of newborns of unknown origin).

Clinical variants of seizures in newborns:

minimal attacks;
generalized tonic;
generalized fragmentary (multifocal) clonic;
focal clonic;
myoclonic.

Neonatal hypocalcaemia (serum calcium in newborns <1.75 mmol/l and ionized calcium <0.87-0.75 mmol/l) may be accompanied by signs of hyperexcitability –hyperesthesia, chin and limb tremor, foot clonus, non-emotional constant screaming, tachycardia with attacks of cyanosis, laryngospasm, inspiratory stridor. In the case of progression of hypocalcemia there are tonic convulsions, vomiting, congestive heart and kidney failure, intestinal bleeding.

In the presence of neonatal hypoglycemia (blood glucose level <2.2 mmol / l) in the initial stages, eye symptoms (nystagmus) appear, the tone of the eyeballs decreases, the oculocephalic reflex disappears, the cry becomes weaker and less emotional, the child vomits. Subsequently, there are attacks of tachycardia, tachypnea, cyanosis, tremor, pale skin, sweating. Weakness, hypotension, hypothermia, anorexia, attacks of irregular breathing and apnea, possible clonic-tonic convulsions progress.

Meningitis in newborns is more often manifested by ocular symptoms, seldom there is an explosion or bulging fontanelle, acute enlargement of the head, rigidity of the occipital muscles, repeated vomiting. Positive meningeal signs.

Clinical manifestations of intracranial hemorrhage in newborns are diverse and depend on the location, massiveness of the process, gestational age, premorbid background. The general condition of the newborn deteriorates sharply with the development of the syndrome of depression, sometimes with signs of periodic hyperexcitability, changes in the nature of the cry, fontanelle bulges. Abnormal movements of the eyeballs, pseudobulbar and motor disorders, convulsions, paresis, disorders of muscle tone are noted.

Hyperthermic (febrile) seizures are typical of young children and can occur if hyperthermia > 38 ° C, have a clonic-tonic nature, last from a few seconds to 15-20 minutes.

Seizures in spasmophilia occur in young children on the background of rickets, usually in winter and spring and have a hypocalcemic nature. The clinic of spasmophilic seizures is diverse and may have local and generalized manifestations. Specific symptoms of increased neuromuscular excitability are pathognomonic. Laboratory spasmophilia reveals hypocalcemia (decrease in total calcium <1.2 mmol / l and ionized <0.9 mmol / l), respiratory or mixed alkalosis.

Affective and hysterical seizures (affective-respiratory attacks) occur in children under 3 years of age at the height of crying or in older children with increased emotional excitability. They are characterized by a tonic component with respiratory arrest on inspiration. Hysteria can cause clonus of the feet and hands.

Convulsions on a residual-organic background are observed in cerebral palsy, Tay-Sachs disease, Niemann-Pick disease, etc. and are characterized by epileptic seizures on the background of delayed psychomotor development.

Differential diagnosis of seizures in children

Deseases	Anamnesis (medical history)	Focal symptoms	Meningeal symptoms	After the attack	Reaction to anticonvulsants
hyperthermic convulsions (febrile seizures)	recurrent seizures on a background of fever	absent/non-available	absent/non-available	consciousness is preserved	anticonvulsants are needed rarely, effective antipyretics
VRI with toxicosis	the anamnesis typical of VRI	absent/non-available	variable	coma after the attack	reaction is positive in combination with glucocorticoid therapy, oxygen therapy
serous viral meningitis and encephalitis	typical of VRI. Headache, vomiting	can be positive at early stage	marked	coma after the attack	repeated administration of anticonvulsants is often required
epilepsy	in medical history convulsions are possible, birth trauma, convulsions without fever	pass after the attack, feebly marked	variable	sleep after the attack	positive
spasmophilia	signs of rickets in children under 1.5 years of age	increased muscle and tendon tone, (+) symptoms of Trusso, Khvostek	absent/non-available	consciousness is preserved	the positive effect is due to introduction of calcium supplements
hypoxic convulsions	severe respiratory failure	more often missing	absent/non-available	coma	improves after reducing hypoxia
traumatic convulsions	head injury	can be present	absent/non-available	may be in a coma or conscious	repeated administration of anticonvulsants is often required

Examination plan for a child with convulsions

clarification of the circumstances of the attack, recording the duration of the attack (the duration of the attack is more than 10 minutes is an indication for urgent hospitalization of the patient)
finding out the anamnesis of the disease (assessment of pregnancy, childbirth/delivery, family medical history, the presence of previous seizures, previous use of antiepileptic drugs)
physical examination to determine BP, RR, HR
assessment of neurological status (presence of focal symptoms)
CBC; clinical urine tests
biochemical analysis of blood (levels of glucose, electrolytes, acid-base balance, bilirubin, urea, etc.);

If necessary, the following can be administered:

ECG, neurosonography, electroencephalogram, skull radiography,
computed tomography or magnetic resonance imaging of the head
lumbar puncture
examination for detecting infectious agents (PCR of blood and cerebrospinal fluid to the most common viruses)
examination by an ophthalmologist, infectious disease specialist, endocrinologist, psychiatrist and other specialists

Emergency treatment for seizures

check the airway permeability;
turn the child to the side in order to prevent possible aspiration, to protect against mechanical injuries, putting soft things under the head and/or back;
oxygen support with 100% humidified heated oxygen, if necessary – artificial lung ventilation;
provide reliable venous access (better catheterization of central veins);
introduce anticonvulsants:

- drugs of the first choice – benzodiazepines: 0.5% solution of seduxene (diazepam, relanium, sibazone) intravenously (rarely intramuscular) in a single dose of 0.2-0.35-0.5 mg/kg body weight (one ampoule of seduxen contains 10 mg in 2 ml). Repeated administration (2-3 times) is possible within 5-15-20 minutes in case of recurrence of seizures. In children <5 years the total dose is 5 mg, in the elderly – 10 mg;

- in case of inefficiency of seduxen action, water-soluble hydantoins (phenytoin, fengidan) are used in a single dose of 10-15 mg/kg. The total dose is not more than 30 mg/kg (ECG is necessary due to the high risk of arrhythmias); sodium oxybutyrate - 20% solution in a single dose of 50-100 mg/kg intravenously (slowly);

- if the previous therapy is ineffective, water-soluble phenobarbital is used in a dose of 5-10 mg/kg. A single dose can be administered every 20-30 minutes to a total dose of 30-40 mg/kg.

In case of ineffectiveness of previous drugs, as well as if the seizures last more than 30 minutes, it is necessary to prescribe general anesthesia using a ventilator. The drugs of choice are short-acting barbiturates (sodium thiopental), which is simultaneously administered intravenously and intramuscular in a total dose of 8-10 mg/kg (not more than 15-20 mg / kg).

Criteria for the effectiveness of the prescribed treatment are the disappearance of seizures and epileptic activity in monitoring the bioelectrical activity of the brain.

Emergency care for seizures that occur on the background of metabolic disorders:

In the presence of hypoglycemia:

20% glucose solution at a dose of 2 ml / kg iv slowly followed by intravenous drip of 10% glucose solution at a dose of 2.4-4.8 ml / kg for 1 h before the elimination of hypoglycemia.

In the presence of hypocalcemia:

10% solution of calcium gluconate at a dose of 0.5-1-2 ml / kg per day for 2-3 doses intravenously slowly, followed by administration of the drug enterally or parenterally if needed.

In children with manifestations of hypomagnesemia:

25% solution of magnesium sulfate at a dose of 0.2-0.4 ml / kg i / m every 8-12 hours on the first day and 1 time per day in the following period.

If the seizure attack lasts more than 30 minutes it is a high risk of cerebral edema. The following measures should be taken to prevent:

limit fluid intake (not more than 75% of baseline)
administration of furosemide 1 mg / kg intravenously
raised position of the patient (30 degrees)