Quick Walk through Seizures in Children, in Uganda

1. Seizures in childhood
Dr. David Sserunjogi

2. Objectives
1. Introduction and epidemiology
2. Mechanism of seizures
3. Types of seizures
4. Management of a seizure

3. Introduction,
epidemiology
● Definitions
● Seizures, Epilepsy
● Status Epilepticus
● Brief stats

4. Introduction
- A seizure is a transient occurrence of signs and/or symptoms
resulting from abnormal excessive or synchronous neuronal
activity in the brain. (Nelson Textbook, 19thEd, Ch.586).
- A seizure is a brief episode of involuntary movement that may
involve a part of the body (partial) or the entire body
(generalized) and is sometimes accompanied by loss of
consciousness and control of bowel or bladder function. (WHO,
2022)

5. Introduction
- A seizure that lasts longer than 5 minutes, or having more than 1
seizure within a 5 minutes period, without returning to a normal
level of consciousness between episodes is called;
status epilepticus. (John-Hopkins).
- Alternatively; status epilepticus is defined as continuous
seizure activity or recurrent seizure activity without regaining of
consciousness lasting for > 30 min. (Nelson Textbook, 19thEd, Ch.586).

6. Introduction
- Epilepsy is a disorder of the brain characterized by an enduring
predisposition to generate seizures and by the neurobiologic,
cognitive, psychological, and social consequences of this
condition. (Nelson Textbook, 19thEd, Ch.586).
- Epilepsy: one or more unprovoked epileptic seizures/ EEG-data
- Epileptic syndrome: disorder with one or more specific seizure
types and has a specific age of onset and a specific prognosis. E.g
West Syndrome.

7. Epidemiology
- Epilepsy affects over 50m ww, 4-10 per 1,000 - active seizures.
- Nearly 80% epilepsy live in low- and middle-income countries.
- 3-fold risk of premature death in epilepsy, (WHO, 2022).
- In Uganda, prevalence of epilepsy is 2%, for age <15yrs. BMC, 2016
- 70%, could live seizure- free if properly diagnosed and treated.

8. Epidemiology
- Status Epilepticus (SE): 7 - 40 cases per 100,000 persons/year.
- SE is more common in males than females.
- 16 - 38% of children with SE, have a history of epilepsy.
- 7.6 - 22% of SE cases present a short-term mortality (within 30
days): across all age groups and is highest amongst the elderly.
(Stat. Pearls. PubMed. May 15, 2022)

9. The Four
mechanisms of
Seizures
● Underlying Etiology
● Epileptogenesis
● Epileptic state of increased
excitability
● Seizure related neuronal injury

10. Underlying Etiology
- Disruption of neuronal functions; they are diverse.
- Seizures may be provoked or unprovoked.
- Provoked: by organic causes such as electrolyte disorders, fever,
- Head injury, Infectious diseases, SOL, Strokes, gene mutations e.g
in Na-K, GABA channels
- In many, how the etiology insults the brain is unknown

11. Epileptogenesis
- Brain turns epileptic, as a result of repeated brain stimulation
- Through activation of glutamate & tropomyosin-rkB receptors
- Increasing neuronal Ca++, >>> Ca-dependent gene expression
- Promotes e.g hippocampal axon formation (mossy fibers)
- Which mossy fibers compensate for epileptic cell death
- Mossy fibre sprouting causes increased brain excitability

12. Epileptic state of increased excitability
- In a seizure focus; each neuron has a Paroxysmal Depolarization
shift (PDS) which is a sudden depolarization phase due to
activation of Glutamate & Calcium gates.
- And an afterhyperpolarization phase due to K+ & GABA
activation
- When disruption occurs in significant number of GABAergic
neurons, inhibitory surround is lost.
- Then a population of neurons fire at same rate & time >> seizure

13. Seizure related neuronal injury
- Apoptosis and necrosis of neurons occur in involved regions
- Evidenced on surgically resected epileptic tissue
- Often demonstrated by MRI, after prolonged status epilepticus
- In many; acute swelling in hippocampus,
- And long-term hippocampal atrophy with sclerosis on MRI

14. Types of
seizures
● Self-limiting vs Continuous
● Generalized vs Focal
● Brief definitions of subtypes
● Febrile convulsions

16. Brief definitions of sub-types
- Tonic: sustained contraction. Clonic: rhythmic contraction
- Myoclonic: rapid shock-like contractions, usually < 50 msec in
duration, that may be isolated or may repeat but usually are not
rhythmic
- Absence: staring, unresponsiveness, and eye flutter lasting
usually for few seconds
- Hyperkinetic: agitated thrashing or leg pedaling movements.

17. Brief definitions of sub-types
- Automatism: nonpurposeful, stereotyped, repetitive behaviors
- What’s a Convulsion! (ILAE, 2017)

18. Febrile Seizure
- Age of 6 - 60 months with a temperature of 38° C or higher,
- No CNS infection or metabolic imbal., no prior afebrile seizures.
- A simple febrile seizure: generalized, usually tonic-clonic, lasting
for a maximum of 15 min, and not recurrent within a 24-hour.
- A complex febrile seizure: is more prolonged ( > 15 min), is focal,
and/or recurs within 24 hr.
- Febrile status epilepticus is a febrile seizure lasting > 30 min.

19. Generalized Seizure
- Can be primary (bilateral) or secondary (unilateral focus).
- Can involve LOC, Eye rolling, Falling, Sudden Cry.
- Tonic phase is followed by clonic phase. May last 1-2min.
- Involve incontinence, Post-ictal: sleepy, headache, dysreflexia
- First aid: Lateral positioning, airway, avoid use of foreign object
to open the mouth.

20. Focal Seizure
- Approximately 40% of siezures are focal or partial
- Can be Simple or Complex (with LOC, Automatisms)
- Focal sezures can become generalized (incontinence, tongue biting)
- Part of the brain, e.g frontal seizures often occure at night.
- EEG can be normal in 15% epileptics due to deep foci.
- MRI is superior to CT scan in investigating foci e.g tumors

21. Management
of seizures
● Approach to a seizure
● Managing a convulsing child
● Convulsive Status Epilepticus

23. Managing a convulsing child
At 5 min
ABC, IV access, Glucose level, O2.
IV Diazepam 0.3mg/kg over 1-2min
Rectal Diazepam 0.5mg/kg (max. 20mg)
NB: Start with Phenobarb in Neonates, at
20mg/kg, maintain at 5mg/kg/day
At 10 min
Second dose of diazepam, Do not
exceed two doses. Keep ABC in
check
At 15-20 min, suspect S.E
IV Phenobarbitone 15-20mg/kg stat, then
5mg/kg/day. Options include: Levetiracetam,
Phenytoin, Valproic acid IV.
At 30 min
IV Phenytoin 20mg/kg in NS,
managing as SE, inform ICU.
(ILAE,2017)

24. Managing Status Epilepticus
Levels of SE Timing Interventions
Early SE 5-10min Diazepam, Repeat at 10min if needed, Alternatives:
Lorazepam 0.1mg/kg, Midazolam 0.15mg/kg slow IV
Established SE 10-30min Phenobarbital. Alternatives Phenytoin 20mg/kg, Levetiracetam
40-60mg/kg, Valproate 40mg/kg, Fosphenytoin.
Inform ICU. Perform EEG or CT where possible.
Refratory SE 30-60min Transfer to ICU, Intubate, Therapeutic Coma, EEG monitoring.
Midazolam, Propofol, Thiopental, Ketamine
Super-refratory
SE
>24 hours Manage in ICU, Identify and treat cause. Options include:
Topiramate, Pregabalin, MgSO4,
Immunological ( e.g methyl-prednisolone, Rituximab, etc ).

25. Thank you!
References:
Nelson Textbook of Paediatrics
International League Against
Epilepsy, 2017, SE
WHO Facts Sheet for Epilepsy
John Hopkins - Status Epilepticus
Hospital care for children
Uganda Basic Paed Protocols