Case Presentation:

Convulsions in Children
Gregory Chumo
Supervisor: Dr Michuki
Biodata
Name: B.M
Age: 2 year old
Sex: male
Residence: Soweto
Informant: mother
Day 3 post-admission
Chief complaint
• Cough-6/7
• Hotness of body-6/7
• Convulsion-on day of admission
History of presenting illness
• Patient was well until 6 days prior to admission when he presented
with a dry cough, of gradual onset, no diurnal variation, had no
relieving or aggravating factors and was associated with nasal discharge
which was clear non foul smelling, cupios in amount. No difficulty in
breathing nor noisy breathing. No family hx of asthma, no hx of contact
with persons with chronic cough, no night sweats, no faltering growth.
• He had hotness of body of gradual onset, intermittent, relieved
transiently by removal of clothes and OTC paracetamol with no
aggravating factors.
• Associated with 2 episodes of convulsions, each lasting <2minutes
characterized by eye rolling, stiffening then jerky movements of both the
upper and lower limbs. He was unresponsive during the episode, but had
no loss of bowel or bladder control, no lipsmaking, no tongue-bitting. He
had postictal drowsiness. He woke up after the first episode, was playful for
about 2hrs then convulsed again.
• No history of irritability, reduced playfulness, inability to feed nor vomiting.
• No history of travel to malaria endemic areas
• No family history of seizure disorder or epilepsy
• No hx of prior episodes of convulsions.
• Has hx of daycare attendance for the past 3 moths, but his immunization is
up to date.
Past medical and surgery history
• This is his index admission.
• No history of surgery, blood transfusion
• No known food or drug allergies
• No known chronic illness
Birth history
• Prenatal
• Mother went for 6 ANC visits. 1st visit at 14weeks.
ANC profile: blood group- A positive, HB- 12.2g/dl, VDRL and HIV- NR, IFAS
and TT3 was given.
• No history of any chronic illness or complications during pregnancy. No
fevers nor rash.
• Perinatal
Born in hospital via SVD at term, birth weight of 3.4 kg, scored 9,9,10,
cried immediately , required no resuscitation. The labour was uneventful.
had no post natal complication, no hx of NBU admission.
Growth and Developmental milestones
Social smile at 2 months
Neck support achieved at 3 moths
Sat with support at 5 months
Sat without support at 7months
Crawled at 9 months
Stood and walked without support at 1 year
Currently he can run, jump and climb stairs.
He has therefore achieved his milestones in a timely manner.
Growth hx: His plotted height and weight curve are within the median range.
Immunization
Upto to date as per KDVI schedule
Nutritional history
Exclusively breastfed for 6 months
Supplementary feeds introduced with mashed potatoes and porridge
Currently on family diet, no aversions.
Family social history
Last born in a family of 2, 1st born is 4yrs, she is alive and well
Mother is a tailor, father is a mason
Live in a well ventilated 2-bedroomed house.
No insurance cover
No known chronic illness in the family

Review of system
• CVS: No bluish discoloration of extremities or lips, no cold extremities, no easy
fatiguability
• GIT: no diarrhoea, no abdominal swelling
• GUT: Normal urine colour and frequency, no urethral discharge
• MSS: No joint swelling or joint pains
• ENT: no ear discharge
Summary
• B.M, 2 years old boy who presented with cough for 6 days and
hotness of body associated with 2 convulsions on the day of
admission.
Physical Exam on admission(Summary)
• General exam: FGC, no pallor, no jaundice, no dehydration, no
cyanosis. Rhinorrhea bilaterally(clear)
• Vital: T;38.6(H), rr: 38(N), pr-108(N), Spo2:96%
• Systemic exam:
• CNS: AVPU at A, neck soft, not irritable, normal tone
• The rest of the exam was unremakable
Physical examination-Day 3
• General examination
Child was in FGC, not in obvious respiratory distress, clically afebrile,
Not pale, not jaundiced, not dehydrated, not cyanosed, no peripheral
lymphadenopathy, no edema.

Vital signs: R.R. 34 bpm(N), P.R. 88 bpm(N), Temp 36.5(N),SPO2 93(N)%.

Anthropometric measures: Weight 12 K.G(N), MUAC 16(N), head

circumference 49cm(N), height 90cm(N)
Systemic exam
CNS
• Child was alert, not irritable
• PEBRL
• Neck soft
• Kernig’s and Brudzinski signs- negative
• Cranial nerves: Intact
• Motor: Normal muscle bulk, power and tone
Systemic exam
• Respiratory system:
Inspection: No nasal flaring, No obvious deformities/scars
Chest moving symmetrically with respiration
No LCWI
Palpation: Trachea not deviated
No palpable mass
Percussion: Resonant
Auscultation: Bilateral air entry with vesicular breath sounds heard
No added sounds
SYSTEMIC EXAM
• CVS:
Capillary refill immediate, with warm peripheries, pulses palpable, normal volume
Normoactive precordium
S1 and S2 heard with no murmurs

• Per abdomen:
Inspection: Moving with respiration, normal fullness with no scars
Palpation: Non tender and no organomegaly.
Percussion: Tympanic
Auscultation: Bowel sounds were present
• B.M, 2 years old boy who presented with cough for 6 days and
hotness of body associated with 2 convulsions on the day of
admission.
• The only positive findings on the day of admission was fever(38.6) and
rhinorrhea.
• His physical exam on day 3 of admission was unremarkable.
Impression
Febrile seizures 20 Upper respiratory tract infection
Differentials
Meningitis
Malaria
Encephalitis
Electrolyte imbalance
Pneumonia
Plan
Investigations Complete blood count- WBC-
CBC 13.3(H),Granulocytes-9.2 (H),
lymphos-6.09(H) H.B. 12.0 g/dl(N),
RBS Platelets 308(N)
UECs RBS-4.6mmo/l
Ca
Blood slide for malaria-Negative
LP for CSF analysis
Lumbar puncture-not done
Blood slide for Mps
Treatment
• Supportive
Encourage feeding.
Antipyretics paracetamol- 180mg TDS PO
Encourage exposure of the baby whenever he’s febrile.
Monitor vital signs. Neurological assessment regularly.
Definitive management.- Probable meningitis
Ceftriaxone 600mg IV 12hrly for 10days.
Discussion : Convulsions In Children
Outline
• Definition
• Classification
• Etiology
• Evaluation of a patient with convulsions: Hx&PE, Inv
• Management
Definitions
• Seizure: a transient occurrence of signs and/or symptoms due to abnormal
excessive or synchronous neuronal activity in the brain. (ILAE, 2017)
• Convulsion: A convulsion is a type of seizure that involves sudden, involuntary
muscle contractions.(Motor seizure)
• Epilepsy: At least two unprovoked (or reflex) seizures occurring more than 24
hours apart. Reflex seizures are seizures evoked by specific external (e.g. light
flashes) or internal (e.g. emotion, thoughts) stimuli. Or
• One unprovoked (or reflex) seizure and a probability of further seizures that is like
the general recurrence risk after two unprovoked seizures (e.g. ≥60 %), occurring
over the next 10 years. E.g structural lesions such as stroke, traumatic brain injury.
• Diagnosis of an epilepsy syndrome.
Epilepsy Syndrome
• An epilepsy syndrome is a complex of signs and symptoms that define
a unique epilepsy condition. This includes seizure types, age of onset,
specific EEG characteristics, genetic factors, and sometimes
associated etiological, prognostic and treatment implications.
• Examples: Dravet syndrome, West syndrome, Lenox Gastaut
syndrome, Childhood Absence Epilepsy
• Status Epilepticus: Status epilepticus is a condition resulting either from the
failure of the mechanisms responsible for seizure termination or from the
initiation of mechanisms, which lead to abnormally prolonged seizures (after
time point t1). It is a condition that can have long-term consequences (after time
point t2), including neuronal death, neuronal injury, and alteration of neuronal
networks, depending on the type and duration of seizures.
Provoked vs Unprovoked
• Provoked Seizure: Seizure that occurs as an immediate consequence
of a specific and identifiable cause or trigger. This could be due to
factors like metabolic imbalances, fever (febrile seizure), drug or
alcohol withdrawal, acute head injury, or acute CNS infections.
• Unprovoked Seizure: Seizure that occurs without an immediate
identifiable cause or trigger. These seizures may occur spontaneously
and are often associated with epilepsy. They are not directly caused
by any identifiable acute condition but may be related to an
underlying chronic condition or a structural brain abnormality. E.g
Seizures in epilepsy with no apparent trigger, occurring months after a
brain injury
Classification
Classification
1. Type of onset
• Focal onset seizure (partial seizure): originate within networks limited to
one hemisphere.
• Generalized onset seizure: originating at some point within, and rapidly
engaging, bilaterally distributed networks.
2. Level of awareness
• Focal with impaired awareness
• Focal with awareness
• Generalized seizures usually have impaired awareness
3. Motor vs Nonmotor seizures
Motor Seizures(Focal, General onset)
• Tonic: sustained focal stiffening
• Clonic: rhythmic jerky movement of limbs
• Tonic clonic: stiffening+ jerky movement
• Myoclonic: Irregular, brief jerking, shock-like (Clonic-sustained more regular)
• Epileptic spasms: Sudden flexion, extension, or mixed flexion-extension
movements involving the neck, trunk, and extremities.
• Atonic: Sudden loss of tone involving limb, trunk, head, jaw.
• Hyperkinetic: Seizures characterized by intense motor activity involving large
amplitude movement, e.g rocking, or pedaling movements. They are usually focal
in onset.
• Automatisms: Purposeless, repetitive motor activity,e.g lip smaking, chewing.
Non-motor (Focal onset)
• Autonomic Seizure: Seizures involving ANS function in CVS, GIT, sudomotor,
vasomotor, thermoregulation e.g palpitations, flushing, piloerection, GIT senstations
• Behavior Arrest: Sudden cessation of voluntary activity during a seizure. The
individual may freeze and remain motionless for several seconds to minutes.
• Cognitive Seizure: Seizures with prominent cognitive symptoms, such as confusion,
decreased responsiveness, or disorientation e.g disturbances in memory(de javu),
hallucinations
• Emotional Seizure : presents with emotional disturbances such as sudden fear,
anxiety, anger, joy, or other intense emotions without an apparent external
cause.e.g sudden laughing(gelastic), sudden crying(dacrystic)
• Sensory Seizure: involves sensory symptoms such as tingling, numbness, visual
disturbances, auditory hallucinations, or other sensory phenomena.
Generalized non motor(Absence seizure)
• Typical Absence Seizure: Characterized by sudden onset and cessation of
staring with unresponsiveness, usually lasting 10-20 seconds. May include
subtle motor manifestations like eye fluttering or lip-smacking. Rapid recovery.
• Atypical Absence Seizure: Similar to typical absence seizures but with a more
gradual onset and resolution. Duration is often longer than typical absences
and may be associated with more pronounced motor symptoms.
• Eyelid Myoclonia: Brief, repetitive, rhythmic jerking of the eyelids, often with
upward deviation of the eyes. It can occur with or without impairment of
awareness and is frequently triggered by closing the eyes or photic stimulation.
• Myoclonic Absence: Seizures characterized by rhythmic myoclonic jerks,
typically of the shoulders and arms, combined with impairment of awareness.
The jerks occur in a rhythmic pattern, usually 2-3 per second, often
accompanied by a staring spell.
 Etiology of Epilepsy
Vascular Metabolic
• Ishemic Stroke, Cerebral hemorrhage • Electrolyte imbalances (e.g., hyponatremia, hyperNa,
hypoCa, HypoMg
• Vascular malformations
• Hypoglycemia, Metabolic acidosis, uremia, liver failure
Infectious • Inborn errors of metabolism (e.g., phenylketonuria)
• Bacterial- Meningitis, abscess, tuberculoma Iatrogenic
• Viral; Encephalitis, meningitis • Drug withdrawal (e.g., benzodiazepines)
• Protozoal: Toxoplasmosis, cerebral malaria • Side effects of medications (e.g., antibiotics(penicillins,
• Helminthic: Neurocysticercosis quinolones, tramadol, antidepressants)
Neoplasia
Trauma
Congenital
• Traumatic brain injury, Post-traumatic epilepsy
• Genetic disorders (e.g., Dravet syndrome, tuberous
Toxins sclerosis)
• Alcohol, lead poisoning. • Developmental anomalies (e.g., cortical dysplasia,
Autoimmune lissencephaly
Perinatal Events
• Autoimmune encephalitis, Lupus (Systemic Lupus
• HIE, Birth trauma, Near drowning, NNM
Erythematosus)
Evaluation 1: History
• Seizure Description: Duration, frequency, onset, and offset.
Description of preictal, ictal and postictal phase
Preictal:
Mood changes (e.g., irritability),
Fatigue or sleep disturbances,
Headache , Gastrointestinal symptoms (e.g., nausea)
Auras: These are specific sensations or experiences that immediately precede
the seizure and are considered a part of the seizure itself, especially in focal
seizures. Sensory symptoms (e.g., visual or auditory changes, strange smells
or tastes) Psychological symptoms (e.g., déjà vu, fear)
• Ictal phase: Determine if it’s a seizure or a mimic(syncope)
-Describe the witnessed seizure activity: Generalized, focal, awareness
-Subtle body movements (e.g., eye blinking, lip smacking)
- Eye rolling, tongue bitting, incontinence
- Awareness: responsiveness
Postictal phase
-How long did it take for the child to get back to baseline condition? Period between
subsequent convulsions, if any, was there return of consciousness,
-Postictal symptoms: confusion, drowsiness, incontinence, irritability, Todd's paralysis,
Triggers:
• Recent infections (features of CNS infection-lethargy, irritability, HA, projectile
vomiting), fever + extraCNS infections, head trauma, starvation.
• Sleep deprivation, stress, flashing lights.
Perinatal History:
• Birth history: complications e.g prolonged labour, resuscitation
• NBU stay.
• Sero-exposure
Developmental History:
• Milestones: delay or regression.
Immunization History
• Esp Pentavalent, PCV 10.
Family History:
• History of epilepsy, febrile seizures, genetic disorders.
Medication and Substance Use:
• Current medications, recent changes.
• Exposure to toxins, substance use.
Seizure mimics
• Breath holding spells- Episodes where a child holds their breath, often in response to
frustration, anger, or pain, leading to cyanosis and sometimes loss of consciousness.
• Syncope-
• Migraine aura
• GER (Sandifer Syndrome); Arching of the back and stiffening of the body in response
to acid reflux.
• Tics
• Functional neurogenic disorder
• BPPV
• Daydreaming, panic attack
• Startle reflex
Evaluation 2; Physical Exam
• Vitals signs(Fever, tachycardia,bradycardia, tachypnea)
• Skin lesions – petechiae(meningococemia), ash leaf spots in tuberous sclerosis
• Systemic Examination
• CNS –
LOC:AVPU, irritability
Head circumference
Fontanelles,
Motor; Tone, reflexes, Babinski reflex
Meningeal signs
• Signs of trauma
• Signs of increased intracranial pressure
• Fundoscopy – look for papilledema – suggests an increase ICP
Evaluation 3; Investigations
Lab investigations
• CBC and differential
• Electrolytes
• Calcium, magnesium
• Blood glucose level
• Toxicology
• Metabolic disease : LFTS, Ammonia,
Lactate, Pyruvate, Amino
acids, Urine organic acids
• LP; Ro Meningitis
Neuroimaging and EEG
• EEG: Second unprovoked seizure.
Normal interictal EEG, negative in 50%,
therefore low NPV.
• CT Scan: Head Trauma, Hemorrhage,
SOL
• MRI: In presence of focal deficits,
recurrent, prolonged seizures
• Cranial USG: Infants, assess structural
abnormalities, ventricles, meningitis,
encephalitis, cysts
Management: Prehospital(Patient Education)
-Stay Calm
-Ensure Safety:
• Move sharp objects or hazardous items away from the child.
• Place the Child on Their Side: Helps keep the airway clear and prevents
choking.
• Place a soft item under the head to prevent injury.
• Do Not Restrain
• Do Not Put Anything in the Mouth.
• Time the Seizure: If it lasts more than 5 minutes or if another seizure starts
before the child recovers, call emergency services.
Hospital Management; > 1 month
Hospital Management: Neonates
AEDs
• Monotherapy>Combination therapy
• Monitor Side effects
• Control=Zero convulsions
• Taper after 2-5 year seizure free period, individualized, risk of
recurrence.
• Remission in epilepsy; seizure-free for a period of at least 10 years,
with the last 5 years being off antiepileptic drugs
Examples
Action of ion channels Enhance GABA transmission Inhibit excitatory amino acid
transmission
Sodium: Phenytoin Benzodiazepines Felbamate
Carbamazepine Barbiturates Topiramate
Lamotrigine Valproic acid
Topiramate Gabapentin
Valproic acid Vigabatrin
Topiramate
Calcium: Ethosuximide Felbamate
Valproic acid
Side effects of anticonvulsants
Drugs Neurologic Systemic
Phenytoin Dizziness, Diplopia, Ataxia, Gum hyperplasia,
Incoordination, Confusion lymphadenopathy, hirsutism,
osteomalacia, skin rash

Carbamazipine Ataxia, dizziness, diplopia, vertigo Aplastic anaemia, leukopenia, GIT

irritation, hepatotoxicty and
hyponatremia

Valproic acid Ataxia, sedation and tremors Hepatotoxicity, thrombocytopenia,

GIT irritation, weight gain, transient
alopecia, hyperammonemia

Lamotrigine Dizziness, diplopia, sedation, ataxia, Skin rash, steven-Johnsons

headaches syndrome
Side effects of anticonvulsants
Drug Neurologic Systemic
Phenobarbitone Sedation, ataxia, confusion, Skin rash
dizziness

Ethosuximide Ataxia, dizziness, diplopia, vertigo GIT irritation, skin rash, bone
marrow suppression

Topiramate Psychomotor slowing, sedation, Renal stones(avoid use with other

speech/language problem, fatigue carbonic anhydrase inhibitors),
and paresthesias glaucoma, weight loss
Febrile seizures
Febrile seizures are seizures that occur between the age of 6 and 60
months with temperature of 38 degree or higher, that are not as a
result of CNS infection or any metabolic imbalance, and in absence of a
history of prior afebrile convulsion
Criteria: A convulsion associated with temp>38 degrees
A child >6months < 6 years
Absence of CNS infection or inflammation
Absence of acute systemic metabolic abnormality that may
cause convulsion
No history of previous afebrile seizure
Classification
• Simple febrile seizure-Most common, characterized by seizure
associated with fever that are generalized, usually tonic-clonic, less
than 15 min and do not recur in a 24 hour period
• Complex febrile seizure-Seizure associated with fever that are
characterized by episodes that have a focal onset, last longer than 15
min or occur more than once in 24hours
• Febrile status epilepticus- Febrile seizure lasting >30 min/intermittent
seizure without neurologic recovery
Epidemiology
• The most common neurologic disorder of infants and young children
• Occurs between the age of 6months to 6 years
• Occurring in 2-4% of children <5 years
• Peak incidence 12-18 months
• Male predominance m:f 1.6:1
Risk factors
• Age
• High grade fever
• Infections
• Immunization-Especially after measles mumps rubella(MMR) vaccine
• Genetic susceptibility-Family history of febrile seizures
Risk factors for recurrence of febrile
seizures
Major
Age<1 year
Duration of fever <24hours
Fever 38-39 degrees
Minor
Family history of febrile seizure
Family history of epilepsy
Complex febrile seizure
Male gender
Investigations
Random blood sugar
Urea, electrolytes and creatinine
Complete blood count
Lumbar puncture and CSF analysis if:
• Presence of meningeal signs and symptoms
• Infants between 6-12 months if immunization status for H.influenza
and strep. Pneumonia is undetermined
Blood slide for malaria
EEG