1) Further questions
a)Is patient well before the presentation or already having condition like fever, irritability, altered consciousness
b) Past medical history of the patient (epilepsy, on medication, birth history predisposing to seizure)
c)Episodes of seizure (is it first episode or patient already have this problem previously)
d)What patient did when seizure occurs (watching TV, playing with tools, sleeping, eating)
e)Nature of seizure (focal, generalized, absence)
-Jerky movement
-Up rolling of eye ball
-Cyanosis
-Urinary/ bowel incontinence
-Increased in salivation.
f)Consciousness during the seizure
g)Duration of the seizure
h)Frequency (if more than one, did patient regain consciousness in between seizure)
i)Any trauma occurs in relation to seizure ( biting tongue, head trauma)
j)Off set (spontaneous vs medication)
k)Family history of epilepsy, first degree relative having febrile seizure.
2)In defining seizure, important key words to be mentioned
-A clinical event
-Resulting from sudden disturbance of neurological function.
-Caused by abnormal or excessive neuronal discharge.
** Epilepsy: recurrent seizure without febrile condition and in the absent of acute cerebral insult.
** Febrile seizure: seizure + fever (usually during the peak of fever)
3)Causes of seizure
a)Febrile seizure
-Simple
-Complex
b)Metabolic
-Hypoglycaemia
-Hypocalcaemia / hypomagnesemia
-Hypo / hyper natremia.
c)Infection (meningitis, encephalitis or any infection that cause high grade temperature.)
d)Poison / toxin / drug ingestion.
e)Head trauma.
f)Epilepsy
-Idiopathic
-Cerebral tumor
-Neurodegenerative disorder
-Neurocutaneous syndrome
-Secondary causes (cerebral dysgenesis, cerebral vascular occlusion, cerebral damage)
4)Differential diagnosis of seizure
a)Rigors
b)Reye’s syndrome
c)Breath holding attack
d)Gastroesophageal reflux
e)Syncope
f)Pseudoseizure.
5)Simple vs complex febrile fit
| Simple | Complex |
| Duration < 15 minutes
| Duration > 15 minutes |
| Generalized seizure | Focal |
| Does not recur during febrile episodes | Multiple seizure |
| | Residual neurological deficit post ictallly. |
6)Criteria for admission to wards
a)1st non febrile seizure for investigation
b)Suspected intra cranial pathology
c)To treat secondary causes of seizure (metabolic, etc)
d)High possibility that seizure will recur
e)Parent requested to be admitted (anxious, stay far away from hospital, difficult transportation)
7)Outline of management
Notes:
i.Most of the time, seizure is brief and does not require intervention.
ii.Management can be divided into general and diagnosis targeted.
General management
a)Positioning the patient into semi prone to avoid aspiration.
b)Maintain adequate airway, breathing and circulation (do not put oropharangeal airway during fitting episodes)
c)Termination of convulsion
-Rectal diazepam 0.5 mg/ kg. maximum 10 mg (for easier way. Infant 2.5 mg and more than 1 year 5 mg*
-Iv diazepam 0.1-0.25 mg/ kg.
-If not abate, manage as status epilepticus. Consider phenytoin infusion, phenobarbitone, midazolam or sodium valproate)
-In neonate, phenobarbitone is more preferred to diazepam.
d)Determine the cause of seizure.
-Blood investigation (FBC, CBS, RFT/LFT and drug screening if history suggestive)
-Imaging if required (CT scan, MRI)
-Lumbar puncture if meningitis or encephalitis is suspected.
-EEG if needed.
e)Further management is based on diagnosis.
-Febrile seizure can be managed by lowering down the temperature (syrup PCM, tepid sponging, cooling the baby)
-Epilepsy should be managed by neurology paediatrician.
-Referral to neurosurgeon if there is intra cranial mass.
8)Discharging the patient
-When patient no more fitting and recurrence fitting is unlikely
-Patient is active and well
-Patient can tolerate orally
-Parents are confident to take care of their children and easily come to hospital if seizure recurs.