CLIPP case 19. 16 month-old with seizure

Question 1

16 month-old boy with a shaking episode, followed by unresponsiveness. Brought in by paramedics after father called 911.

Answer 1

DDx:

• Seizure
• Syncope d/t breath-holding spell (1-3yo)
• Meningitis/encephalitis
• Toxic ingestion
• Trauma with LOC
• Intussusception
• Motor tics
• Myoclonus
• GERD (Sandifer’s syndrome)
• Pseudoseizure

Question 2

Seizure DDx

Answer 2

• Febrile seizure
• CNS infection (meningitis/encephalitis)
• Idiopathic epilepsy
• Ingestion/poisoning
• Head trauma
• Metabolic disturbance

Question 3

Seizure classification

Answer 3

• Generalized tonic-clonic
• Absence (petit-mal)
• Simple partial
• Complex partial

Question 4

Generalized tonic-clonic seizure

Answer 4

• Most common type in children
• Begins with tonic stiffening of all extremities and upward deviation of the eyes -> Clonic jerks of all extremities -> Flaccid with urinary incontinence

Question 5

Absence seizure

Answer 5

aka petit mal

• Generalized seizure, but consciousness regained more quickly
• Seen in children starting around age 3
• Loss of environmental awareness, automatisms. No loss of tone
• May be precipitated by hyperventilation or photic stimulation

Question 6

Simple partial seizure

Answer 6

• Motor signs in a single extremity or one side of the body

- Focal onset seizure activity may spread to become generalized

Question 7

Complex partial seizure

Answer 7

• Alteration of consciousness is hallmark feature
• Signs and symptoms tend to localize around eyes, mouth, abdomen
• Commonly accompanied by automatisms, quasi-purposeful motor or verbal behaviors that are repeated inappropriately
• 30sec-2min. Postictal phase
• Secondary generalization can occur

Question 8

Febrile seizures

Answer 8

• Usually occur on first day of illness
• Hereditary
• Acetaminophen and ibuprofen do not prevent recurrence
• Parents should be reassured that recurrent, simple febrile seizures have no long-term effects on child development
• Simple febrile seizure: More common, < 15 minutes, occur once in a 24-hour period, generalized
• Complex febrile seizure: Less common, > 15 minutes, occur more than once in a 24-hour period, focal

Question 9

Bacterial meningitis

Answer 9

• 2 months to 12yo: S. pneumo and N. menin. Younger: GBS and E. coli
• Empiric tx: 3rd gen cephalo + vancomycin x 7-14 days

Question 10

Bacterial meningitis complications

Answer 10

• Stroke
• Subdural effusion
• SIADH
• Seizure
• Developmental delay
• Hearing loss

Question 11

CSF in bacterial meningitis

Answer 11

• Glucose low
• Protein high
• WBC high with PMN predominance

Question 12

CSF in viral meningitis

Answer 12

• Glucose normal
• Protein normal
• WBC high with early PMN and later lymphocytic predominance