The document discusses convulsive disorders in children, including febrile seizures and epilepsy. It defines febrile seizures as seizures precipitated by fever between 6 months and 6 years of age. Epilepsy is defined as recurring seizures that can be classified as partial or generalized. Diagnostic procedures and treatment principles for seizures are also outlined.

1. CONVULSIVE DISORDES
Najah Qasem
Qassim University 1

2. Objectives:
1- define the etiological factors of seizures in children.
2- discuss febrile convulsion in children and its treatment.
3- list classification of epileptic seizures.
4- explain characteristics for epileptic seizures’ types.
5- identify diagnostic procedures .
6- numerate treatment principles for epilepsy
7- identify seizures precautions.
8- formulate nursing care plan for a child with epilepsy.
9- discuss status epilepticus and initial approach treatment.
10- plan drug study for some medications.
2

3. OVER VIEW
 Convulsive phenomena are among the most
frequently observed neurological
dysfunctions in children and can occur with a
wide variety of conditions involving the C.N.S
 3-5% of all children will have one or more
seizures .
 The incidence of epilepsy (new cases per
year) has been reported to be 50/100,000
3

4. Etiology of Seizures in
Children
classification of seizures is presented
in the following :
 A) Acute/Non-recurrent
(i) with fever: febrile convulsion, infections e.g.
meningitis, encephalitis. .
(ii) without fever: poisoning including medicinal
overdose, metabolic disturbance e.g.
hypoglycemia, hypocalcaemia and electrolyte
imbalance, head injury, brain tumor.
4

5. Etiology of Seizures in
Children
 B) Chronic/Recurrent :
(i) with fever: recurrent febrile
convulsion.
(ii) without fever: epilepsy.
5

6. Febrile seizures
 Febrile convulsions, the most common seizure
disorder during childhood.
 Occurring between 6 months and 6 years.
 Precipitated by fever from:
infection/inflammation/metabolic disorders .
 It is not a form of epilepsy because brain is
normal.
6

7. Febrile seizures
 In most cases it is generalized tonic - clonic
convulsion. and lasts a few seconds to less
than 15 minutes with a loss of consciousness.
 There is no preceding aura and the child
may be postictal (confused) for a short time
after the seizure is over.
 A strong family history of febrile convulsions.
7

8. Clinical Picture
 Febrile convulsion is divided into
three main groups based on symptoms of the
seizure:
 Simple febrile convulsion (convulsion
occur in majority of the cases ~
75%, lasting less than 15 minutes , not
having focal features, single in 24 hours).
 Complex febrile convulsion: represent
25% of the cases, lasting more than 15
min, with focal features, multiple in 24
hours.
 Febrile status epilepticus. 8

9. Treatment of
Febrile Seizures
 A careful search for the cause of the fever.
 Use of antipyretics.
 Reassurance of the parents.
 Prolonged anticonvulsant prophylaxis for preventing
recurrent febrile convulsions is controversial and no longer
recommended.
 Oral diazepam, 0.3 mg/kg/8h or (1mg/kg/24hr), is
administered for the duration of the illness (usually 2–3
days).
 Vaccination is not contraindicated.
 No treatment is effective in decreasing risk of future
epilepsy.
9

10. Counseling of the Parents
 Parents should be informed about the
benign nature of febrile convulsion and that it may
recure.
 Parents should be taught to manage the
convulsion by placing the child in recovery
position (lying in his or her side to prevent
aspiration and control fever).
 After the seizure subsides, parents should
sponge the child with tepid water to reduce the
fever quickly.(applying alcohol or cold water is not
advisable, because extreme cooling cause shock
to an immature nervous system)
10

11. Epilepsy
 Epilepsy is a group of syndromes characterized
by recurring seizures.
 seizure is an involuntary contraction of muscle
caused by abnormal electrical brain discharges.
 Epilepsy can be primary (idiopathic)
or secondary, when the cause is known and the
epilepsy is a symptom of another underlying
condition such as a brain tumor
11

12. Classification of Epileptic
Seizures (recurrent seizures)
 Partial (Focal) seizures:
 Simple partial seizures (no altered level of
consciousness)
 Simple partial seizures with motor signs
(include aversive, rolandic, and jacksonian
march).
 Simple partial seizures with sensory signs.
 Complex partial (psychomotor) seizures
(some impairment or alteration in level of
consciousness) 12

13. Classification of Epileptic
Seizures (recurrent seizures)
 Generalized seizures
 Generalized tonic – clonic seizure
(Grand Mal)
 Absence seizures (Petit Mal).
 Atonic seizures (Drop Attacks)
 Myoclonic seizures.
 Akinetic seizures
 Infantile spasms
13

14. Partial (Focal) Seizures
Simple partial seizures with motor signs:
It arises from the area of the brain that controls
muscle movement. A common motor seizure in
children is:
14

15. Partial (Focal) Seizures
i) Aversive seizure:
 the eye or eyes and head turn away from the side
of the focus.
 In some children the upper extremity toward which
the head turns is abducted and extended.
 The fingers are clenched giving the impression
that the child is looking at the closed fist.
 The child may be aware of the movement.
15

16. Partial (Focal) Seizures
ii) Rolandic seizure:
 Tonic- clonic movements involving the face.
 Salivation.
 Arrested speech.
 Most common during sleep.
 It is the common form.
16

17. Partial (Focal) Seizures
iii) Jacksonian March:
 Consists of orderly, sequential progression of
clonic movements that begin in a
foot, hand, or face, and as electric impulses
spread from the irritable focus to contiguous
regions of the cortex, move or march body
parts activated by these cerebral regions.
17

18. Partial (Focal) Seizures
2. Simple partial seizures with sensory signs:
 Characterized by various sensations including
numbness, tingling, prickling, or pain that originates
in one area e.g. face or extremities and spreads to
other parts of the body.
 Visual sensations or formed
images, hallucinations, tight
flashes, tastes, smells, or sounds may be
experienced.
 Autotonic activity may include 18
pallor, sweating, flushing, and pupil dilation.

19. Partial (Focal) Seizures
3. Complex Partial Seizures
(Psychomotor Seizures)
Vary greatly in extent and symptoms and tend to
be the most difficult type to control.
 Are observed more often in children from 3
years of age through adolescence.
 May begin with a slight aura in the form of
sensation of strange feeling at the bottom of the
stomach that rises toward the throat.
 This feeling may be accompanied by unpleasant
odors or taste, complex auditory or visual
hallucinations.
19

20. Partial (Focal) Seizures
Cont..
 Impaired consciousness ; the child may appear
dazed and confused and be unable to respond
when spoken to or to follow instruction.
 Automatisms (repeated activities without purpose
and carried out in a dreamy state), such as
oropharyngeal activities as chewing, drooling, or
swallowing.
 Ambulatory activities as wandering or running and
verbal manifestations such as repeating word.
20

21. Generalized Seizures
I- Tonic - Clonic Seizures:
(Grand Mal)
 It is consisting of four stages:
A- prodromal period of hours or days.
B- an aura, or warning, immediately before the
seizure.
C- the tonic-clonic stage
D- postictal stage.
* Not all four stages occur with every seizure.
21

22. cont..
A- prodromal period of hours or days.
May consist of drowsiness, dizziness, malaise, lack
of coordination, or tension.
B- an aura, or warning, immediately before the
seizure.
May reflect the portion of the brain in which the
seizure originates. Smelling unpleasant odors
denotes activity in the medial portion of the
temporal lobe. Seeing flashing lights suggests the
occipital area. Repeated hallucination arise from
the temporal lobe.
22

23. cont..
C- the tonic-clonic stage
Tonic phase:
 rolling of the eyes upward
 immediate loss of consciousness
 stiffness in the entire body muscles, and the child falls to
the ground.
 arms usually flex, whereas the legs, head and neck
extend.
 lasts approximately 10 to 20 seconds
 the child is an apnea and may become cyanotic
 Autonomic stimulation causes increased salivation.
23

24. cont..
Clonic phase:
 intense jerking movements as the trunk and the
extremities undergo rhythmic contraction and
relaxation.
 child may foam at the mouth and incontinent of
urine and feces.
 It lasts about 20 to 30 seconds up to 30 miutes.
24

25. cont..
D- postictal stage
 Falls into a soundly sleep for 1 to 4 hours and will
rouse only to painful stimuli during this time.
 Child may have visual and speech difficulties and
may vomit or complain of severe headache.
 The child has no memory of the seizure.
25

26. 2- Absence Seizures:
(Petit Mal)
 Occur more frequently in girls than boys
 Onset of absence seizures is abrupt and the
child suddenly develops up to 100 attacks daily.
 Brief loss of consciousness with minimal or no
alteration, usually consist of a staring spell that
lasts for a few seconds.
 Rhythmic blinking and twitching of the mouth or
an extremity may accompany the staring.
 The sudden -rest of activity and consciousness
is not accompanied by incontinence, and the
child has amnesia for the episode.
26

27. cont..
 Slight loss of muscle tone may cause the child to
drop objects, but he can maintain postural control.
 usually lasts approximately 5 to10 seconds.
 usually have normal intelligence, however, if they
have frequent episodes, they may be doing poorly in
school because they are missing instructional
content.
 Petit mal seizures can be precipitated by
hyperventilation, fatigue, hypoglycemia, stresses
(emotional and physiological) or sleeplessness.
27

28. 3- Atonic Seizures:
(Drop Attacks)
 Manifested as a sudden, momentary
loss of muscle tone.
 Onset is usually between 2 and 5 years of age.
 During a mild seizure the child may simply
experience several sudden brief head drops.
 During a more severe episode, the child will
suddenly fall to the ground and will lose
consciousness briefly and after a few seconds will
get up as if nothing happened.
 Frequent falls can result in injury to
face, particularly the chin, eyebrow and nose area.
28

29. 4- Myoclonic seizures:
 Include sudden, brief contractions of
a muscle or group of muscles.
 No loss of consciousness or postical state.
 Myoclonus often appears normally in the course of
falling asleep.
 May be confused with the exaggerated startle reflex,
but may be distinguished by placing one's palm
against the back of the child's head, if it is possible to
push the child's head forward, this indicates an
exaggerated startle reflex. In case of a myoclonic
seizure, the child's head resists attempts to bring
head forward.
29

30. 5- Akinetic seizures:
Are characterized by
 lack of movement, however muscle tone is
maintained so the child freezes into position
and doesn't fall. If the child is lying down, the
evaluation of muscle tone helps to
differentiate between the atonic and Akinetic
type seizure. There is impairment or loss of
consciousness
30

31. 6- infantile spasm:
(unclassified seizures)
characterized by
 Very rapid movements of the trunk with sudden
strong contractions of most of the body, including
flexion and adduction of the limbs.
 The infant suddenly slumps forward from a sitting
position or falls from a standing position.
 These episodes may occur singly or in clusters as
frequently as 100 times a day.
 Most common during the first 6 months of life
 Apparently result from a failure of normal organized
electrical activity in the brain.
31

32. 6- Infantile Spasm:
(unclassified seizures)
 the seizures may accompany a preexisting form of
neurologic damage. In approximately 50% of those
affected, there is an identifiable cause such as trauma
or a metabolic disease. In the other 50%, there may
be no identifiable cause.
 Approximately 90% of these infants are
developmentally delayed
 In infants whose development was previously
normal, intellectual development appears to halt and
even regress after seizures start.
 The infantile seizure phenomenon seems to “burn
itself out” by 2 years of age but the associated
cognitive or developmental delay remains.
32

33. Diagnostic Evaluation:
Has two major aims:
1. To identify the type of seizures the child has
experienced, their frequency and severity, and
the factors that precipitate them
2. To attempt to understand the cause of it.
It includes:
i. Perform complete history, physical examination
and neurologic examination,
ii. Rule out metabolic causes with measurements
of serum glucose and electrolytes. 33

34. Diagnostic Evaluation:
iii. Electroencephalography (EEG) records
electrical activity of brain.
iv. Radiographic examination identifies cranial
abnormalities.
v. Single photon emission computed tomography
(SPECT).
It is useful for identifying the epileptogenic zone
so that the area in the brain giving rise to
seizures can be removed surgically
34

35. Abnormalities in the EEG usually continue between seizures or, if not
apparent, may be elicited by hyperventilation or during sleep.
35

36. Treatment of Epilepsy
principles
 Drug treatment should be regular
 Simple as possible
 Minimum of side effects
 Monotherapy
 Changes should be made gradually
 High initial dosages increases side effects
 Rapid withdrawal carries the risk of provoking
status
 Always calculate the dosage according to the
weight
36

37. SEIZURE PRECAUTIONS
Extent of precautions depends on
type, severity, and frequency of seizures
May include:
 Siderails raised when child is sleeping or resting
 Siderails and other hard objects padded
 Waterproof mattress/pad on bed/crib
 Appropriate precautions during potentially
hazardous.
37

38. SEIZURE PRECAUTIONS
 Swimming with a companion
 Use of protective helmet and padding during
bicycle riding.
 Supervision during use of hazardous
machinery/equipment
 Have child carry or Wear medical identification
 Alert other caregivers to need for any special
precautions
38

39. Nursing Care Plan for the
Child with Epilepsy
1- Nursing Diagnoses:
High risk for injury related to sudden seizure, tonic-
clonic seizure
Goal:
Child exhibits no signs of aspiration or traumatic injury.
Nursing interventions:
1- If child is standing or sitting in wheelchair at beginning
of attack, ease child down so that he will not
fall, when possible place a blanket under child.
39

40. Nursing interventions:
2- Remain with child, and be calm.
3- Loosen restrictive clothing.
4- Prevent child from hitting head on sharp objects
that might cause injury.
5- Remove hazards (Furniture).
6- Pad objects such as crib.
7- Keep side rails raised to avoid falls.
8- Gently support child. Do not force hard object
between the teeth when Jaw is tightly closed.
40

41. Expected outcome:
Child exhibit no evidences of physical injury.
Goal 2:
Prevent seizures.
Nursing interventions:
1- Avoid situations that are known to precipitate a
seizure as blinking light, emotional stress, loud
voice.
Expected outcome:
Child remains free of seizure activity.
41

42. 2- Nursing diagnosis:
self concept disturbance in body
image, self esteem, personal identity
related to seizure onset
Goal:
Develop a positive self concept.
Nursing interventions:
1- Encourage child to express feelings and concept
about the disease.
2- Encourage child to discuss his thoughts about his
disorder.
3- Help child asses his strengths.
4- Emphasize strengths.
5- Help child set realistic goals.
42

43. 3- Nursing Diagnosis:
Altered family process related to
emergencies hospitalization of child,
knowledge deficit.
Nursing Diagnosis: Interrupted family processes
related to diagnosis of long-term illness in child
Goal 1:
Support parents.
Nursing intervention:
1- Allow expression of feelings
regarding the child's disorder, its implications.
2- Refer to organizations to seek advice.
3- Be available to families for help. 43

44. Expected outcome:
 Family expresses feelings and concerns.
 Family contacts agencies for help.
Goal 2:
Understand the disease
Nursing intervention:
1- Assist family in understanding the disorder, its
therapies, and possible complications.
2- Help family to achieve realistic view about the
child and his capabilities.
Expected outcome:
Family demonstrates an understanding the
disorder, its therapy and implications.
44

45. Goal 3:
Prevent complications from medication
Nursing intervention:
1- Be aware of and teach family recognizes
unfavorable reactions to medications.
2- Encourage periodic physical and laboratory
assessment to determine deviations from normal
findings.
Expected outcome:
Child and family demonstrate understanding of possible
unfavorable responses to medication and the
appropriate intervention,
Goal 4:
Prepare family for home care.
45

46. Nursing intervention:
1- Teach administration of medications.
2- Teach seizure prevention and
management.
3- Educate parents and child about appropriate activities
for the child:
- Avoid contact sports.
- Avoid situations that pause a danger during a
seizure like climbing trees.
- Provide companionship during permissible activities
such as swimming, bicycling.
Expected outcome:
1- Family complies with instructions.
2- Family demonstrates proper management of the child
during a seizure.
3- Child exhibits no evidence of physical injury.
46

47. Status Epilepticus
 Refers to a seizure that lasts continuously for longer
than 30 minutes or a series of seizures from which
the child doesn’t return to his or her level of
consciousness.
 Three major subtypes:
 prolonged febrile seizures
 idiopathic status epilepticus
 symptomatic status epilepticus
 Severe anoxic encephalopathy in first few days of
life.
 The relationship between the neurologic outcome
and the duration of status epilepticus is unknown in
children. 47

48. Complications
 It is emergency situation that need immediate treatment
 Hypoxemia
 Acidemia
 Glucose alterations
 Blood pressure disturbances
 Increased intracranial pressure
 High Morbidity
 Neurologic sequelae
 Focal motor deficits
 Mental retardation
 Behavioral disorders
 Chronic epilepsy
 Acute and chronic MRI changes
 High mortality (3-4%)
48

49. Prolonged seizures
Life
Temporary
threatening
systemic Death
systemic
changes
changes
Duration of seizure
49

50. Management of Status Epilepticus
in Children--Initial Approach
 Initial assessment
 A, B, Cs
 Rapid neurologic examination
 Brief history
 Give high flow oxygen
 Measure rapid blood glucose
 More to avoid glucose infusion than the uncommon hypoglycemic
seizures
 Confirm epileptic seizure
 Not all events are epileptic!!!!
 Laboratory Studies
 Glucose, electrolytes, calcium, magnesium
 ABG
 CBC
 Serum anticonvulsant drug levels (if indicated)
 Toxicology screening
50

51. Treatment of status epilepticus
 Drugs:
 should always be administered IV
 phenytoin forms a precipitate in glucose solutions
 have resuscitation equipment at the bedside
 diazepam may be used initially
 if the seizures persist, phenytoin is given immediately
 The choices for further drug management include
paraldehyde, a diazepam infusion, barbiturate coma, or
general anesthesia.
51

52. Drug study examples
 Drug study for Phenobarbital
Classification: CNS depressant.
Action: acts as an anticonvulsant by lowering the seizure
threshold.
Dosage: 3 to 6 mg/kg/day parenterally, for 7 to 10 days until
a blood level of 10 to 15 µg/ml is achieved, or 10 to 15
mg/kg/day IV or IM.
In status epilepticus , 15 – 20 mg/kg IV administered over 10
to 15 minutes.
Possible adverse effects: sedation, confusion, lethargy,
excitement, nausea, vomiting, constipation, diarrhea,
epigastric pain, bradycardia, hypotention, syncope,
hypoventilation, respiratory depression, pain or tissue
necrosis at the injection site.
52

53. Nursing implication
1- when giving phenobarbital parenterally, administer IV dose
slowly, direct into tubing or running infusion. Inject a partial
dose and assess the response before continuing. If giving
phenobarbital IM administer it deeply into a large muscle.
2- monitor the IV site carefully for signs of irritation or
extravasation.
3- assess vital signs closely during IV administration.
4- administer oral form of the drug with food to minimize
gastrointestinal upset, instruct the parents to do the same.
5- caution the parents and child that the drug will make the
child drowsy. Advise the child to change positions slowly and
to sit at the edge of the bed for a few minutes before arising.
Assist parents with safely measures to protect the child from
injury.
53

54. Nursing implication
6- monitor laboratory tests for liver and renal function and blood
counts if the child is on long-term therapy.
7- inform parents about the possible need for follow-up
laboratory tests.
8- suggest that the parents obtain a medical alert bracelet and
have the child wear it in case of emergency.
9- instruct parents and child to avoid over-the-counter drugs,
which could cause increased CNS depression.
10- warn parents not to discontinue the drug abruptly or change
the dose unless ordered by the health care provider.
11- instruct parents to notify the health care provider if the child
develops severe dizziness, weakness, or drowsiness that
persists.
54

55. Drug study examples
 Drug study for Phenytoin (Dilantin)
Classification: it is an anticonvulsant.
Action: Stabilizes neuronal membranes, prevents
hyperexcitability caused by excessive stimulation, and
limits the spread of seizure activity without causing
general central nervous system depression
Dosage: Initially, 5 mg/kg/day in two to three equally
divided doses up to a maximum of 300 mg/day with a
maintenance dose of 4 to 8 mg/kg/day.
Possible Adverse Effects: Nystagmus, ataxia, slurred
speech, confusion, fatigue, irritability, nausea, gingival
hyperplasia, liver damage, and blood dyscrasias
55

56. Nursing Implications
1- Administer the drug with food to minimize gastrointestinal
upset and enhance absorption. Instruct parents to do the
same.
2- Advise parents to have the prescription filled each time with
the same brand of drug, because differences in
bioavailability have been reported.
3- Obtain serum drug levels as ordered to monitor for
effectiveness and to prevent possible toxicity. Keep in mind
that the therapeutic range is 10 to 20 µg/mL.
4- Monitor liver function studies and blood counts periodically.
5- Inform parents about the need for follow-up laboratory
tests.
56

57. Nursing Implications
6- Instruct the child and parents about oral hygiene
measures to prevent gum problems. Encourage frequent
dental checkups.
7- Suggest that the parents obtain a medical alert bracelet
and have the child wear it in case of an emergency.
8- Caution parents not to discontinue the drug abruptly or
change the dose unless ordered by the health care
provider.
9- Instruct parents to notify the health care provider if the
child develops nystagmus, ataxia, or diminished mental
capacity. These are signs of possible toxicity.
57

58. 58