Seizures

R56.8

• Description
• Diagnostic criteria
• General and supportive measures
• Medicine treatment

DESCRIPTION

A seizure is a change in movement, attention or level of awareness that is sustained or repetitive and occurs as a result of abnormal and excessive neuronal discharges within the brain.

For recurrent seizures, see:Epilepsy .

Classification of seizures using International League against Epilepsy (ILAE)
Classification of seizures is aetiological and clinical.

Aetiology

• Genetic
• Structural-metabolic
• Unknown

The causes of seizures are multifactorial.
The commonest seizures in children are febrile convulsions but the history, examination and investigations must be aimed at excluding the following conditions:

Clinical

Within each of the above categories, generalised, focal or syndromic seizures occur.

Generalised seizures:
The epileptic focus arises at some point within and rapidly spreads to involve networks in both hemispheres of the brain.
Generalised seizures may be:

• tonic-clonic,
• absence (typical or atypical),
• clonic,
• tonic or atonic,
• myoclonic.

Generalised tonic-clonic seizures (GTCS) that continue or recur for more than 5 minutes in which there is incomplete recovery of consciousness are called Convulsive Status Epilepticus: See: Status epilepticus (convulsive) .

Focal seizures:
The epileptic activity arises at some point from a particular focus or networks limited to one hemisphere of the brain.
Focal seizures occur with:

• observable aura, motor or autonomic components.
• altered consciousness or awareness (previously termed) complex partial seizures.

The presentation of focal seizures depends on the site of origin and may be frontal lobe seizures, temporal lobe seizures, parietal lobe seizures and occipital lobe seizures.

Focal seizures may progress to generalised tonic-clonic seizures and this is known as secondary generalisation.

Epileptic Syndromes – See: Epilepsy .

DIAGNOSTIC CRITERIA

Clinical

• Obtain a history:
  • eye witness account, aura, video recording.
  • perinatal history, drug history, developmental history, school record, family history and environment.
• Examine to exclude obvious aetiology, but in particular look for occult causes:
  • general: skin abnormalities, e.g. Sturge-Weber syndrome and tuberous sclerosis complex.
  • CNS examination for loss of consciousness, neck stiffness, localising signs, head growth, developmental milestones and fundoscopy.
  • CVS examination: check blood pressure.

Investigations

Investigations should be individualised according to clinical indication.

Always consider hypoglycaemia as a primary or aggravating cause of any seizure.

Basic investigations:

• Blood glucose in all children.
• Rapid test for malaria for those who have recently travelled to a malaria area.
• Electrolytes (Na, Ca, Mg) in sick and young children.
• Blood culture in febrile children.
• Full blood count.
• Lumbar puncture: if meningitis is suspected.
  It is difficult to clinically exclude meningitis in children under 12 months, therefore, a LP may be warranted.

Note:

If the seizure has progressed to established status epilepticus (i.e. lasted 20-30 minutes), then lumbar puncture is contraindicated until raised intracranial pressure is excluded. For contraindications to LP see Lumbar Puncture .
Neuro-imaging: CT scan (brain) - if persistently reduced coma score (GCS < 12/15) without known cause, raised intracranial pressure or focal intracranial pathology is suspected.

GENERAL AND SUPPORTIVE MEASURES

• Ensure an open airway and administer oxygen.
• Position to prevent aspiration of vomitus, i.e. recovery position.
• Check glucose during the seizure and blood pressure after the seizure.
• Obtain intravenous access if seizure duration is > 5 minutes.
• Keep child nil per mouth and intravenous fluid volumes at maintenance rates.
• Aetiology will determine further management.

MEDICINE TREATMENT

(Of a first-time febrile related seizure.)

For fever:

• Paracetamol, oral, 15 mg/kg/dose 6 hourly, as required.

In an unconscious child, administer paracetamol rectally.

• Paracetamol suppositories, rectal, 6 hourly.

Note: Suppositories should not be divided, as the amount of paracetamol in each portion may not be consistent.

Urgent medicine treatment is indicated if the seizure is generalised and lasts more than 5 minutes or is causing systemic compromise. Treat as for Status epilepticus: See: Status epilepticus (convulsive) .