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SEIZURE RECOGNITION, SEIZURE
TYPES, FIRST AID AND SAFETY
Charuta Joshi MBBS, FRCPC
Director of pediatric epilepsy
UIHC
Objectives
At the end of this lecture the participants will be able to:
Define a seizure
Recognize different types of seizures
Define epilepsy
Know basic steps involved in seizure first aid
Name 2 different medications used on the site to treat seizures in the
prehospital setting
Be familiar with ketogenic diet as therapy for seizures
What is a seizure
Seizure recognition
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A clinical manifestation of :
Abnormal
Excessive
Paroxysmal
Electrical discharge in neurons
Seizure recognition
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Stereotyped
Repetitive
If unsure video tape events
Ask pediatrician to see
Seizure recognition
• Spectrum of findings
Generalized seizures
Complex partial seizures
Simple partial
seizures
Seizure recognition
simple partial seizures
• Localization
Seizure recognition
Generalized
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Absence
Myoclonic
Tonic
Generalized tonic clonic
How important is it to be sure about a
seizure
First seizure clinic results
• 127 children
• 94 were given diagnosis of epilepsy in first
seizure clinic
• 36 had suffered at least one previous seizure
( 15 unrecognized by family as a seizure)
• 31 – non epileptic events
• Unclassified in 2
Differential diagnosis
Investigations after a first unprovoked
seizure
Investigations
Yield of neuroimaging
(Shinnar et al 2001)
What is epilepsy
• Tendency to have recurrent, unprovoked
seizures
• 2 or more unprovoked seizures separated by
24 hours
Questions parents have after seizures
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Will it happen again?
How long do I have to wait for a recurrence?
Could my child die during a recurrence?
Could there be brain damage due to
recurrence
• If medication treatment is delayed will there
be change in long-term chance of permanent
remission?
Recurrence risks
• Recurrence rate at 2
years 40-50%
• Half the recurrences are
within 6 months of
initial seizure
• 80% of 5 year
recurrence risk
stabilizes by 2 years out
Risk factors for recurrence
• Remote symptomatic etiology
• Abnormal EEG ( any spikes, generalized spike wave,
focal or generalized slowing)
• Occurrence of seizure during sleep state (increases
chance of recurrence)= lower morbidity than during
daytime seizure
• Risk of recurrence after 2 seizures is 80%
Do you treat a first seizure
• Treatment reduces the risk of a second seizure
by 50% at 2 years
• Immediate treatment DOES NOT reduce risk of
long term seizures
• Treated and untreated groups have a 64%
chance of 5 year remission at 10 years (MESS
study)
• Risk of toxicity, allergic reaction, cognitive side
effects
Risks of morbidity/ mortality due to
seizures- could my child die??
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692 children in Nova Scotia ( Camfield 2002)
Followed =20 years
26 deaths
1 from status
1 from SUDEP as an adult at age 22 years
Could my child die
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Dutch study of childhood epilepsy ( Callenbach 2001)
472 children followed for 5 years
9 deaths
None from epilepsy
Connecticut study ( Berg 2004)
613 children followed for 7.8 years
13 deaths
1=status
1=SUDEP
When does immediate treatment
matter
• When risks of recurrent seizures outweigh
benefits of withholding treatment ( adults)
• Cyanotic congenital heart disease in a child
Seizure first aid
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ABCs
Stay calm
Don’t leave patient alone
Lateral position if possible
Don’t restrain
Nothing in mouth
Call 911
Seizure safety
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Maximize quality of life
Water safety
Safety on roads
High structures
Medic alert, seizure beds, seizure dogs, baby
monitors
Seizure precautions
• Regular sleep
• Alcohol
• Infections
• Photic stimulation
• Substances of abuse
Sports participation has not been shown to
increase risk of seizures
Prehospital treatment of seizures
Operational
definition of
status
Most seizures
stop
0
Time definition of
convulsive status
epilepticus
Optimum time to
start therapy
5
15
30
Medications used for prehospital
treatment
• Diazepam
• Midazolam
• Lorazepam
Prehospital treatment
midazolam
Lorazepam
• 2mg/ml Intensol
• Indicated for anxiety
Faves…
Moving on to a different
discussion now…
Ketogenic diet
• UIHC= The only center in the state
• 30-40 active patients
• Dedicated dietician
Karla Mracek
• Dedicated ARNP
Tiffany Rickertsen
Historical anecdotes
History
• Mac Fadden 1899- magazine
Physical Culture
• Medical profession= Organized
fraud
• People who follow MacFadden’s
rules would live to 120 years
• Since much of the body’s energy
is wasted in digesting food, if no
food is provided, more energy
can be applied to recovering
health
• Dr Conklin-osteopath in
Battlecreek , Mi
• Used diet in epilepsy
Mr MacFadden
• Physical culture
Historical anecdotes
• Conklin’s work( intestinal epilepsy- toxin
release from glands= seizures)
• Conklin’s fast 18-21 days ( or as long as they
could stand it)
Historical anecdotes
• Dr Geyelin worked at Johns Hopkins=
confirmed Conklin's findings
• Dr BJ Wilder= fat can be used to break fast=
no seizures
Charlie foundation
Charlie Foundation
• Mr Jim Abrahams
• Sought help from Johns
Hopkins for his son Charlie
• Seizure free today after
several medications and
neurologists
Movie
Since then…
Indications
Mechanisms of action
Not exactly known
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Ketone bodies= antiepilepsy properties
PUFAs= membrane stabilization
Antioxidative/ antiinflammatory
Uncoupling of oxidative phosphorylation(
better energy utilization)
Types of ketogenic diet
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Classic ketogenic diet= 4:1 ratio
MCT oil diet ( less restrictive)
Modified Atkins diet=15-20 gm carbs/day
Low Glycemic index diet=60 gm carbs/day
Ketogenic diet
Most kids not fat…
Results
• 50-60% improve
• Almost 100% improve –
Doose , GLUT1
Contraindicated
Fatty acid oxidation defect
Thank You !!