Seizure management in pediatric patients for the nineties

Etiological Profile of First Episode Seizures in Paediatric Patients at a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Seizures are the most common neurological emergency and one of the most common reasons for paediatrics hospital admissions. This study aimed to identify the etiology, clinical profile, and immediate outcome of children with the first episode of seizure in Eastern Nepal.

METHODS

This was a prospective descriptive study carried out in the Tertiary Care Centre from September 2022 to August 2023. Ethical clearance was taken from the Institutional Review Committee (Ref no:654/2022). Convenience sampling was done to include 170 children presenting with the first episode of seizure at age 6 months to 15 years. Variables collected were demographics, clinical presentations, family history, trauma history, laboratory tests, neuroimaging, EEG, final diagnosis, and immediate outcome.

RESULTS

A total of 170 patients were admitted with the first episode of seizure with 123 (72.36%) males and 47 (27.64%) females. The mean age of the patients was 5.13±2.95 years with 104 (61.18%) patients under 5 years of age. The most common seizure was generalized tonic-clonic type in 132 (77.64%) patients. The most common associated symptom was fever in 150 (88.23%) children. Neuroimaging was abnormal in 52 (30.59%) patients, with neurocysticercosis seen in 27 (15.88%). The most common etiology was febrile seizure in 92 (54.17%) patients, neurocysticercosis in 27 (15.88%), and meningitis in 12 (7.05%).

CONCLUSIONS

Febrile seizures, neurocysticercosis, infection, and trauma were the major causes of seizures in children. When simple febrile seizures were unlikely, lumbar puncture, neuroimaging, and laboratory tests were useful tools for diagnosing etiologies of seizures.

Intravenous diazepam, midazolam and lorazepam in acute seizure control

OBJECTIVE

To evaluate the safety and efficacy of three benzodiazepine drugs: Lorazepam, Midazolam and Diazepam, when given parenterally in the control of acute seizure.

METHODS

One hundred and twenty children of either sex in the age group 6 month to 14 years brought convulsing to the pediatric emergency services, were enrolled in the study. These were randomised to three equal groups of 40 patients each; Group A-received diazepam, Group B-received midazolam, Group C-received lorazepam. End of seizure episode (clinically) was defined as cessation of visible epileptic phenomenon or return of purposeful response to external stimuli within 15 min of drug administration. A stopwatch was used to measure various time intervals accurately. The patient's vitals were monitored and recorded in a predesigned performa. The primary outcome was the time to seizure cessation and secondary outcome was the side effects of the drugs. Data obtained was analysed statistically using student's t-test and chi-square test.

RESULTS

Mean duration to clinical seizure cessation was comparable among the three groups. For diazepam group it was 84.94 ± 38.56 s, for midazolam group it was 92.69 ± 25.97 s, for lorazepam group it was 91.12 ± 23.58 s. Number of patients with any abnormality in seizure cessation were significantly higher in diazepam group [11/40 (27.5%)] when compared to the midazolam [4/40 (10%)] and lorazepam group [2/40 (5%)]. Number of patients requiring 2nd dose to control seizures was significantly higher [4/40 (10%)] in diazepam group when compared to lorazepam group [0/40 (0%)] but diazepam and midazolam and midazolam and lorazepam were comparable in this aspect.All the three drugs were comparable in terms of side effects except excessive somnolence which was significantly higher in diazepam group.

CONCLUSIONS

All the three groups were comparable in terms of time to clinical seizure cessation, seizure recurrence and uncontrolled seizures after drug administration. However, number of patients requiring second dose to control seizures were significantly higher in diazepam group when compared to lorazepam group. Excessive somnolence and sedation occurred more frequently with diazepam.

New-onset seizures in pediatric emergency

BACKGROUND

Seizures account for 1% of all pediatric emergency department (ED) visits. The aim of this study was to analyze the clinical spectrum and prevalence rates of various etiologies in children with a first attack of acute seizure disorder in the ED.

METHODS

We evaluated 319 children who presented to the ED at the Changhua Children's Hospital with a first attack of seizure disorder from 2005 to 2007. Variables including demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnoses and hospital course were compared between patients with seizures and fever, and patients with seizures without fever. These variables were also compared between patients with simple and complex febrile seizures and among different age groups.

RESULTS

Among these 319 patients, 218 (68%) presented with seizures and fever and 299 (94%) children were younger than 6 years of age. Generalized tonic-clonic seizures were the most common type (71.2%). Febrile seizures (62.1%) were the main etiology of the first seizure (p < 0.001). Seizures caused by severe electrolyte imbalance or hypoglycemia were noted in three patients. Abnormal brain images were noted in 16 (26%) of 61 patients, most (12/16, 75%) of whom had abnormal histories and physical or neurologic examinations.

CONCLUSION

Primary care pediatricians should evaluate children presenting to the ED with a first seizure for age, coexistence of fever, seizure type, associated symptoms and history of head injury. We suggest that electrolytes, blood sugar and emergent brain imaging studies should be arranged based on detailed history-taking and thorough physical examinations, but should not be performed routinely.

Seizures in children

Seizures are the most common pediatric neurologic disorder. Four to ten percent of children suffer at least one seizure in the first 16 years of life. The incidence is highest in children less than 3 years of age, with a decreasing frequency in older children. Epidemiologic studies reveal that approximately 150,000 children will sustain a first-time unprovoked seizure each year, and of those, 30,000 will develop epilepsy. This article describes the types, diagnoses, and management and disposition of this pediatric neurologic disorder.

Intracardiac yolk sac tumor and dysrhythmia as an etiology of pediatric syncope

This report describes a new etiology of pediatric syncope. Epilepsy, brain anomalies, infection, electrolyte abnormalities, and trauma are commonly identified etiologies of seizures in the pediatric population. We report here a child with third-degree heart block and right ventricular outflow tract obstruction related to an intracardiac tumor presenting with syncope and seizure-like activity. Echocardiography revealed a large (3 x 8-cm) intracardiac mass filling the right atrium, extending across the tricuspid valve into the right ventricle and crossing the atrial septum into the left atrium, extending into the left ventricular outflow tract. She underwent emergent cardiopulmonary bypass with removal of the majority of the tumor mass, clearing both the left and right ventricular outflow tracts of obstruction and repairing the tricuspid valve. Postoperative cardiac conduction remained blocked and required permanent pacing. The initial serum alpha-fetoprotein level was grossly elevated, and the tumor showed characteristic histopathologic features of a yolk sac tumor. Four years after the completion of her chemotherapy, she remains clinically well, with no evidence of recurrent tumor by echocardiography or radiographic studies, and her alpha-fetoprotein remains in the normal range. The clinical manifestations of tumor infiltration of the heart with complete heart block resulting in loss of consciousness with tonic-clonic movements are detailed. Although rare, cardiac syncope has multiple known causes and should be suspected in any patient with sudden loss of consciousness and pallor. In the pediatric population, cardiac rhythm disturbances are typically the result, rather than the cause, of acute cardiac emergencies. Pediatricians should be aware of depressed cardiac output and dysrhythmias as etiologies of new-onset syncope. Evaluation should include a cardiac assessment with electrocardiogram to exclude a life-threatening arrhythmia as a potential cause.

Infant seizures not so infantile: first-time seizures in children under six months of age presenting to the ED

Data regarding first-time seizures in children <or=6 months of age is limited. This retrospective study, therefore, reviews the presentation, management, and outcome of children <or=6 months of age presenting to a pediatric tertiary care facility with a first-time seizure. Charts for 31 patients were identified and reviewed. Nineteen patients (61%) received sepsis work-ups. Two of the 31 (7%) had infectious etiologies. One of these infants, a 3-month-old who presented with only a history of fever and eyes rolling back but otherwise appeared well on initial presentation, had pneumococcal meningitis. Neuroimaging studies were performed in 22 (71%) patients with 12 of 22 (54%) having abnormal findings. Electroencephalogram (EEGs) were performed on 22 patients (71%) with 11 (50%) showing seizure activity. Electrolytes were checked on 19 patients (61%) with 5 being clinically significant. Etiologies included idiopathic (32%), congenital anomalies (26%), inborn errors of metabolism (16%), electrolyte abnormalities (16%), infection (7%), and trauma (3%). In conclusion, unlike children >6 months of age in whom febrile seizures and idiopathic seizure disorders are most common, a large percentage of children <or=6 months of age presenting with first-time seizures have significant underlying pathology. This pathology often includes immediately life-threatening conditions in these children who may look deceptively well on initial evaluation.

Utility of laboratory testing for infants with seizures

OBJECTIVES

Study objectives were to 1) determine the frequency with which laboratory studies are obtained, 2) determine the proportion of results that are clinically significantly abnormal, and 3) define the clinical characteristics of those with abnormal results, among infants with nonfebrile seizures (NFSz).

METHODS

A retrospective consecutive cohort study of infants < or = 12 months old presenting to the ED of a tertiary care, children's hospital following a seizure. A 2-year review was performed. Serum chemistry results were classified as "normal," "outside of the normal range," or "clinically significantly abnormal."

RESULTS

Sixty-seven of 134 (50%) with a NFSz were tested compared to 19/80 (24%) with a febrile seizure (FSz, P < 0.001). Nine (5 with hyponatremia and 4 with hypocalcemia) of the 67 (13%) tested NFSz infants had a clinically significant abnormality, as did 9 of 21 (43%) NFSz infants who seized in the ED compared to 0/46 (0%) without ED seizure activity (P < 0.0001). Hypothermia (T < 36.5 degrees C) and age less than 1 month were common characteristics of infants with clinically significant abnormalities.

CONCLUSIONS

This is one of the only studies to have assessed the utility of laboratory testing for infants with seizures. Abnormal serum chemistries accounted for a greater proportion of seizures among this cohort compared to that reported previously for older children. Laboratory testing is recommended for NFSz infants who 1) are actively seizing in the ED, 2) have a temperature below 36.5 degrees C, or 3) are less than 1 month of age.