The fitting child

Question 1

Causes of convulsions

Answer 1

Febrile
Electrolyte imbalance->hyponatremia, hypocalcemia
Drug ingestion
Head injury
Hypoglycemia
Meningitis
Asphyxial injury
Epilepsy

Question 2

Important history/assessment

Answer 2

Any compromise to ABC
Has this happened before- may have diagnosis of epilepsy already-> ?compliance
Description of the event
Duration-> >20 minutes unlikely to suffer long term brain damage
Was the child unwell/pyrexial beforehand->febrile/CNS infection
Is the child developmentally normal
Is drug ingestion/poisoning a possibility
Significant past history->VP shunt, renal/liver, endocrinopathies
Focal features
Any previous anticonvulsant
Evidence of others requiring acute management->hypoG, electrolyte imbalance, meningitis, drug overdose, trauma, stroke

Question 3

Why is it important to know if child is developmentally normal

Answer 3

Non-febrile convulsions are more common in those with learning disability or cerebral palsy

Question 4

Important examination

Answer 4

Ensure open airway
Generalised, focal
Vitals> be sure to check temperature
Any obvious focus of infections
Signs of trauma/head injury
Examine the eyes->flicking, rolling in head
Look for evidence of meningitis
Check the pupils

Question 5

Management of convulsions

Answer 5

1. Supportive management 5-10 minutes
2. Support airway and breathing, apply oxygen by mask, monitor.
3. Secure IV access, check bedside BSL and send urgent specimen for calcium / electrolytes and venous blood gas. If hypoglycaemia present-> correct the low sugar.
4. Give benzodiazepine->rectal diazepam (0.1-0.3mg/kg) or buccal midazolam (0.3 mg/kg) if no IV, give IV/IO if available
5. Repeat benzodiazepine after 5 minutes of continuing seizures.
6. If convulsion continues for a further 5 - 10 minutes, commence IV phenytoin or phenobarbitone. If IV access cannot be secured and seizures refractory to benzodiazepines, consider IO access.
7. Consider pyridoxine (100mg IV) in young infants with seizures refractory to standard anticonvulsants.
8. Seek senior assistance if seizure not controlled. Anticipate need to support respiration. Thiopentone or Propofol and rapid sequence induction (RSI) may be required for seizure control.

Be sure to correct any metabolic abnormalities/hypoglycemia

Question 6

Advice to parents to manage a major seizure at home

Answer 6

Stay calm
Check medical identification
Protect from injury, move objects away
Time the seizure/video
Loosen anything tight around neck
Put something soft under head
Stay with child reassure then
Do not put anything in their mouth
Do not restrain them
When seizure is over roll onto side
Consider if need an ambulance
Try to give privacy away from others

Question 7

Advice to parents to manage minor seizure at home

Answer 7

Stay calm
Check medical IS
Gently guide away from harm
Time/record
Stay with child and reassure them
Try to give privacy

Question 8

How to manage if in a stroller, car seat or wheelchair

Answer 8

leave the child seated if they are secure and safely strapped in
gently hold their head
when the jerking stops, if they are unconscious, take them out of the seat, lay them down and roll them onto their side

Question 9

When to call an ambulance

Answer 9

You should call an ambulance if:

you think it is the child’s first seizure
the seizure lasts more that five minutes
another seizure quickly follows the first one
the child remains unconscious or has trouble breathing after the seizure
the seizure happens in water
the child is hurt or injured
the child has diabetes
the child does not seem to fully recover
you are about to give medications to stop the seizure. For example diazepam or midazolam

Question 10

When is the greatest risk for having another seizure

Answer 10

Within three months of having the first one

Question 11

Parent safety recommendations after a first seizure

Answer 11

1. Develop action plan with GP
2. Medical ID bracelet
3. Child always swims with adult (also needs to be able to swim well)
4. Showers instead of bath
5. Turn cold water on first, lower hot water temperature of service
6. Special care when using hot things that may cause burns
7. Make sure other carers know about the childs epilepsy and can manage appropriately
8. Avoid activities at height unless appropriate supprot
9. Make sure car/home has first aid kit

Question 12

Side effects of carbamazepine

Answer 12

Drowsiness, headache, unsteadiness, dizziness, n/v,

skin rash, agranulocytosis/aplastic anemia (rare)

Question 13

Side effects of valproate

Answer 13

Hepatic failure, headache, somnolence, alopecia,
n/v, diarrhea, tremor, diplopia, thrombocytopenia,
hypothermia, pancreatitis, encephalopathy

Question 14

Investigations

Answer 14

Blood glucose
UEC, CMP
LP if suspect meningitis, beware +ICP
CT/MRI if head trauma, focal neurological signs
Blood/urine/throat/CXR to look for focus of infection
Urine toxicology if drug ingestion/overdose