Seizures and Epilepsy
Lesson Objectives
By the end of this lesson, learners should be able to:
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Differentiate between acute, unprovoked, and epileptic seizures.
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Recognize clinical features of various seizure types in children.
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Identify investigations required for diagnosis and monitoring.
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Manage febrile seizures, epilepsy, and status epilepticus.
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Understand pharmacological management and dosing in paediatric patients.
Description
Seizures in children can be classified as:
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Acute symptomatic seizures: triggered by acute causes, e.g., hypoglycaemia, hypocalcaemia.
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Unprovoked seizures: occur without an identifiable trigger.
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Epileptic seizures: due to abnormal, excessive, or synchronized neuronal activity; may be focal or generalized.
Epilepsy is a chronic condition marked by a predisposition to recurrent unprovoked seizures and associated cognitive, psychological, and social consequences. Diagnosis requires two or more unprovoked seizures >24 hours apart, or a first unprovoked seizure after remote brain insult, or part of a syndrome.
Clinical Features
| Seizure Type | Signs and Symptoms |
|---|---|
| Acute / Epileptic | Muscle spasms, shaking, jerks, head drops, tonic movements (focal or generalized) |
| Febrile Seizures | Tonic-clonic movements, duration <15 mins (simple) or >15 mins (complex), 1 vs multiple episodes in 24 hrs |
| Status Epilepticus | Seizure >5 mins or recurrent seizures without recovery, may be life-threatening |
Investigations
| Test | Purpose / Notes |
|---|---|
| Blood glucose (RBS) | Detect hypo/hyperglycaemia |
| Serum electrolytes | Calcium, magnesium; correct imbalances |
| Toxicology screen | Rule out poisoning |
| EEG | Evaluate seizure focus; not always diagnostic |
| Neuroimaging | Emergent CT/MRI for persistent unresponsiveness, focal deficits, or abnormal EEG |
Febrile Seizure Investigations:
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Fever workup: FBC, CRP, urinalysis/MCS, malaria RDT/MPS
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EEG and neuroimaging only if complex seizure or atypical features
Management
Febrile Seizures
| Route | Drug & Dose | Notes |
|---|---|---|
| IV | Lorazepam 0.05–0.1 mg/kg (max 4 mg) | Administer over 5 min |
| IV | Diazepam 0.1–0.2 mg/kg (max 10 mg) | Alternative to Lorazepam |
| PR | Diazepam 0.5 mg/kg (max 10 mg) | If IV access unavailable |
Epilepsy Management
| Seizure Type | Drug | Dose / Notes |
|---|---|---|
| Focal | Carbamazepine | 5 mg/kg/day once daily for 1 week, then 15–20 mg/kg/day in divided doses (max 35 mg/kg/day or 1.8 g/day) |
| Generalized | Phenobarbital | 2–5 mg/kg/day once daily or 12-hourly |
| Generalized | Sodium Valproate | 10–40 mg/kg/day in 12-hourly doses |
| Generalized | Lamotrigine | Start 0.6 mg/kg once daily ×2 wks, increase 0.3 mg/kg/day weekly |
| Generalized | Levetiracetam | 20–60 mg/kg/day 12-hourly (4–12 yrs max 1500 mg, 12–16 yrs max 3000 mg) |
Note: EEG supports diagnosis but a normal EEG does not rule out epilepsy.
Status Epilepticus
Investigations:
Dependent on suspected cause (missed meds, cerebral malaria, encephalitis, meningitis, stroke, metabolic disorders). Common labs:
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FBC/DC, RBS, electrolytes, creatinine
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LFTs
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Calcium, magnesium, phosphate
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Blood gas analysis, lactate
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CSF studies after brain CT
Treatment Steps:
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Assess and stabilize ABCDE.
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First-line benzodiazepines:
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Diazepam 0.2–0.3 mg/kg IV (max 2 doses)
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Lorazepam 0.1 mg/kg IV over 5 min
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Second-line anticonvulsants:
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Phenytoin 15–20 mg/kg IV over 20 min (max 1 g, dilute in NS only)
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IV Levetiracetam 40 mg/kg (max 1000 mg) over 10 min in 100 mL NS
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Sodium Valproate 20 mg/kg IV or via NGT
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Refractory seizures:
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Additional Phenytoin 10 mg/kg IV
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Phenobarbitone 15 mg/kg IV
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Prepare for intubation and consider general anesthesia if seizures persist
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Evaluate and treat underlying cause concurrently.
Summary
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Seizures may be acute, unprovoked, or epileptic.
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Febrile seizures occur in 6 months–6 years without CNS infection; simple vs complex determines monitoring and treatment.
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Epilepsy is a chronic condition requiring anti-seizure medications individualized by seizure type.
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Status epilepticus is a medical emergency requiring rapid escalation from benzodiazepines to second-line anticonvulsants and possible ICU care.
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Investigations guide cause-specific treatment but supportive care and timely intervention are critical.