protocal of neonatal seizure, includes protocol fron nelson, IAP, AIIMS

1. Protocols of Neonatal
seizure

2. Neonatal seizures (NS) are the most frequent and
distinctive clinical manifestation of neurological
dysfunction in the newborn infant.
Definition:-
A seizure is defined clinically as a paroxysmal
alteration in neurologic function, i.e. motor, behavior
and/or autonomic function.
1. Epileptic seizures: phenomena associated with
corresponding EEG seizure activity e.g. clonic
seizures
2. Non-epileptic seizures: clinical seizures without
corresponding EEG correlate e.g. subtle and
generalized tonic seizures

3. 3. EEG seizures: abnormal EEG activity with no clinical
correlation.
Classification:-
Subtle seizures:
They are the commonest type
1. Ocular - Tonic horizontal deviation of eyes or
sustained eye opening with ocular fixation or
cycled fluttering
2. Oral–facial–lingual movements -
Chewing, tongue- thrusting, lip-smacking, etc.
3. Limb movements - Cycling, paddling, boxing-
jabs, etc

4. 4. Autonomic phenomena - Tachycardia or bradycardia
5. Apnea may be a rare manifestation of seizures. Apnea
due to seizure activity has an accelerated or a
normal heart rate when evaluated 20 seconds
after onset.
Clonic seizures:
They are rhythmic movements of muscle groups. They
have both fast and slow components, occur with a
frequency of 1-3 jerks per second
Tonic seizures:
refers to a sustained flexion or extension of axial
or
appendicular muscle group

5. Myoclonic seizures:
manifest as single or multiple lightning fast jerks
of the
upper or lower limbs and are usually distinguished from clonic
movements because of more rapid speed of myoclonic jerks,
absence of slow return and predilection for flexor muscle
groups
Myoclonic seizures carry the worst prognosis in
terms of neuro-developmental outcome and
seizure recurrence. Focal clonic seizures have
the best prognosis.

6. Aiims protocol:- identify and characterize seizure
Nurse the baby in TNZ( room temp 26’-28’ C)
Maintain airway ,breathing, circulation , start O2
Check blood glucose (<40mg) and give glucose @ 8mg/kg
(2ml/kg of D10 %)
Give 2ml/kg of 10% of ca gluconate over 10 min
0.25ml/kg of 50% mgso4 i/m

7. Phenobarbitone 20mg/kg over 20 min
Give phenobaritone again @ 10mg/kg
Give maintenance dose 3-5 mg/day
Phenytoin 20mg/kg over 20 min
Repeat phenytoin 10mg/kg

8. Benzodiazepines used
Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes or
Midazolam: 0.15 mg/kg IV bolus followed by infusion of 0.1 to 0.4 mg/kg/hour
In refractory seizurez second line drugs can be used
Lidocaine 4mg/kg iv followed by 2mg/kg/hr or

9. Sodium valproate 20-25mg/kg/day followed by 5-10mg/kg/day
Other drugs like vigabatrin. Topiramate, paraldehyde
Therapeutic trial of pyridoxine
1 ml of neurobion on both gluteus i/m

10. IAP Protocol:-
Maintain ABC and temperature
Check blood glucose
Correct glucose and calcium
Administer IV, phenobarbitone 20mg/kg
Repeat in 5 mg/kg boluses till a maximum of 40 mg/kg, every
15 minutes if seizure continues

11. IV phenytoin 15-20 mg/kg diluted in equal volume of normal saline at a
maximum rate of 1mg/kg/min over 35-40 minutes
IV lorazepam (0.05-0.1 mg/kg ) or dizepam ( 0.25 mg/kg bolus
Or 0.5 mg/kg rectal )
IV midazolam as a continuous infusion (as initial IV bolus of 0.15 mg/kg,
followed by continuous infusion (1ug/kg/min ) increasing by 0.5-1
ug/kg/min every 2 minutes until a favorable response or a maximum of
18ug/kg/min
100 mg pyridoxine IV or oral ( if IV not available ) should be given

12. Nelson Protocol:-
Maintain ABC and temperature
Check blood glucose
Correct glucose and calcium
Administer IV, phenobarbitone 20mg/kg
Repeat in 5 -10mg/kg boluses till a maximum of 40 mg/kg,

13. IV phenytoin 15-20 mg/kg diluted in equal volume of normal saline at a
maximum rate of 1mg/kg/min over 35-40 minutes
IV lorazepam 0.05 mg/kg every 4-8 hourly
IV midazolam as a continuous infusion (as initial IV bolus of 0.05-
0.1mg/kg, followed by continuous infusion (0.5-1ug/kg/min ) increasing
by 2 ug/kg/min every 5 minutes to achieve seizure control
Primidone, lidocaine, carbamazepine, valproate, lamotrigine,
topiramate, and levetiracetam have been used.

14. Weaning of anticonvulsant therapy
Newborn on anticonvulsant therapy
Wean all antiepileptic drugs except phenobarbitone
once seizure controlled
Perform neurological examination prior to discharge
normal Abnormal

15. Stop
phenobarbitone
prior to discharge
Continue
phenobarbitone for
1 month
Repeat neurological
examination at 1
month of age
Abnormal
examination
Normal examination

16. Taper drugs over
2 week
Evaluate EEG
Normal EEG
Taper drug over
2 weeks
Abnormal EEG
Continue drug
Reassess at 3
months

17. Dr.Priyank
Patel