Introduction

You will hear many different phrases over the course of your career: ‘funny do’, ‘funny turn’, ‘fit’,  ‘faint’.  However, what these should all mean to the discerning clinician is ‘suspected seizure’.

A seizure is a period of abnormal discharge of neurons in the brain, and can take many forms depending on the site and type of the paroxysmal activity.  The major types of seizure are shown below.

The main types of seizure.

Acute Management

This is vital in real life (and therefore vital to mention in exams!), especially if the ‘suspected seizure’ is occurring right there and then.  Management will differ whether the child is in the community, but an algorithm for hospital management is shown below.  The algorithm can be stopped at any point at which is becomes obvious the child has not or is no longer experiencing a seizure (e.g. patient is lucid, Hx or examination points to different cause).

*You will note the algorithm below is the same as that for status epilepticus, a condition characterised by:

  • a seizure lasting longer than 30mins, or;
  • repeated seizures without the patient regaining consciousness in the intervening periods.

 

Practically, however, the algorithm is started after a seizure has lasted more than 5 minutes.

 

Airway Breathing Circulation Disability Exposure

The immediate management of suspected seizure.

Assessment

History

The history is the most useful diagnostic tool when dealing with a suspected seizure; as such it is imperative to take a comprehensive and detailed history from the child and/or carer as appropriate.  A general paediatric history should be taken, but below is a list of seizure-specific questions to ask.

 

1) Age of the child

This is the first discriminating factor that will aid in cutting down your differential diagnosis, e.g. febrile seizures typically occur in children aged 6 months - 6 years.

 

2) History of presenting complaint - from both child and witness if possible

  • When did it happen?
  • What was the child doing beforehand?
  • Did they experience any warning beforehand, e.g. sensory disturbance?
  • Exactly what happened during the event? - chronological order of events is important, any change of conscious level, any motor phenomenon, colour change?
  • How long did it last? - Seizures will often seem to last a very long time to parents/witnesses. If a parent answers that it lasted '10 mintues' take a moment to say something like, 'Ten minutes is quite a long time. Often seeing a seizure is so distressing it seems to go on a lot longer than it actually does. Do you think it might have been shorter or are you pretty sure it was that long?'
  • Any symptoms after the event? - if so, how long until the child returned to normal?
  • Recent history of infection or fever?
  • Has this ever happened before? - if so, was this event exactly the same as before?  (Take history of other events if not)
  • NB Associated symptoms such as headache, vomiting or ataxia?

 

3) Past medical/surgical history

  • Fever?  Signs of meningitis?
  • Previous febrile convulsion?
  • Medications?
  • Is the child seeing any other physicians?  Why?
  • Congenital syndromes / chromosomal abnormalities - e.g. trisomy 13 (Patau's)

 

4) Obstetric history

  • In utero
  • At birth
  • As a neonate

 

5) Developmental history

This is typically important. However, always be ready to justify relevance, particularly to examiners - e.g. 'Epilepsy is more common in autistic spectrum disorders, therefore history of social development is pertinent.'

  • Gross motor
  • Fine motor & vision
  • Speech & hearing
  • Social

 

6) Family history

  • Any history of events (similar or not) in other relatives?
  • History of epilepsy?
  • Consanguinity

 

7) Social history

  • How is the child doing at school? Has this recently changed?
  • Any recent changes in the child's social situation?

 

8) Systems review

 

Examination

A full review of a paediatric neurological examination is outside the scope of this article, but four general areas are important to examine:

  • temperature - pyrexial?
  • any focal neurology
  • skin - ?neurocutaenous syndromes (e.g. tuberous sclerosis, NFM)
  • fundus - ?congenital infections or neurodegenerative diseases

 

Investigations

History will often indicate which (if any) investigations need performing, but here is a list of investigations that may prove useful in establishing a diagnosis:

  • Blood and urine biochemistry - U&Es, FBC, LFT, calcium, glucose
  • Infection screen if fever present - blood cultures, urine cultures, lumbar puncture
  • Toxicology screen
  • ECG
  • MRI/CT imaging if evidence of focal lesion or developmental delay
  • EEG only if a diagnosis of epilepsy is already suspected

 

    Differential Diagnosis

    The differential diagnosis of seizure.

    It is important that, until a diagnosis is confirmed, carers are advised on how to manage a genuine seizure and avoid specific dangers (e.g. injury from falling, swimming, unprotected heat, moving objects and machinery). This is necessary even if non-epileptic disorders are strongly suspected.

     

    Potential OSCE Stations

    • History of seizure
    • Neurological examination
    • Counsel the concerned parent of a child who has had a febrile seizure

     

      Counseling a concerned parent about a febrile convulsion is very difficult. They will typically ask:

      • Will it happen again?
      • Can I prevent further episodes?
      • What should I do if a convulsion happens again?
      • Is it my fault?
      • Is it epilepsy? Is my child at a higher risk of developing epilepsy?
      • *See Fastbleep article on 'Febrile seizure'.

       

        Suggested OSCE Revision Tasks

        • Take a history of suspected seizure 
        • Discuss febrile convulsions with a concerned parent 
        • Practise neurological examinations - this can come up in paediatric OSCEs even if you have not done neurology yet!
        Advertisement

        Fastbleep © 2019.