Fits

Question 1

T/F: Fits are quite common in children.

Answer 1

true

4/1000 children will have epilepsy, and quite a few more than that will have had a single fit at some time.

NB: convulsions, seizures and fits - all the same thing.

Question 2

Some children are simply prone to fits, and often grow out of them, but sometimes fits are caused by a significant brain problem e.g. ?

Answer 2

encephalitis, head injury, poisoning or child abuse.

Question 3

commonest cause of fits in children where parents seek emergency help?

Answer 3

high temperature > febrile convulsions.

Question 4

T/F: most fits are generalised seizures

Answer 4

true

They usually last 2-3 minutes and stop by themselves.

Question 5

• A fit usually has to last ?? or more before brain damaged occurs due to the fit itself.
• Recommended that treatment is given or an ambulance is called if the fit lasts more than ??

Answer 5

• 1/2 hour
• 5 minutes (because most fits don’t, and it may take >20 ins to get treatment for it or for it to start to work

Question 6

T/F: Epilepsy is a term we use when fits recur.

Answer 6

true - a bit like wheezing and asthma, the diagnosis isn’t usually made on just one occasion.

Is best that a neurologist makes the diagnosis, as misdiagnosis is fairly common.

Question 7

Important consideration when taking a Hx of a seizure?

Answer 7

try as hard as possible to get an eyewitness account, even if this is over the phone, and to take the person through exactly what they saw

Question 8

What to cover in the Hx of a patient presesenting with seizure?

Answer 8

1. warning and awareness
2. appearance
3. duration
4. HA

Then go back over the past day or 2 to see if you can establish a cause for the fit (recent illness, changes in meds, head injury, drugs & alcohol, metabolic abnormalities, low glucose, birth history, developmental history)

Question 9

name some non-seizure and true seizure causes of fit-like episodes

Answer 9

Question 10

what is syncope and what is the commonest cause?

Answer 10

• a drop in blood pressure which causes loss of consciousness
• commonest reason is a simple vasovagal faint.

Question 11

Hx which might suggest syncope is the cause?

How can it be differentiated from a true seizure?

Answer 11

• child usually describes funny vision such as tunnel vision or going black, sound becoming distant, and weakness of their legs
• As well as a few jerks as they faint, incontinence can also happen. This is more likely if they are not laid flat, to improve the blood pressure.
• The difference is in the recovery phase which is swift. The patient is back to normal in a minute or so.

Question 12

The blood pressure can also drop if there is a cardiac arrythmia. How to differentiate from a vasovagal faint?

Answer 12

• same appearance as a vasovagal faint, although the patient is often described as pale.
• circumstances also different - instead if the typical things which cause faints (prolonged standing, hot/ emotional environment), a cardiac syncope happens out of the blue or on exercise.
• It is common for the child not to feel any palpitations even when the cause is an arrhythmia.

This event requires cardiac investigations, so if you are not confident there was a good reason for a faint, ensure the child is followed up in a hospital.

Question 13

T/F: vasovagal faints usually happen from about 7 years onwards, not younger children

Answer 13

true

Question 14

Some younger children are prone to an exaggerated vasovagal reaction when they suffer pain or emotion.

This leads to breath-holding attacks, where the child stops breathing and goes pale or blue.

In a more severe attack, _____ can occur temporarily and a true seizure can happen, called a __ __ __

T/F: these are sinister and require further investigation by specialist neurologist.

Answer 14

asystole

reflex anoxic seizure

false - in fact totally harmless and kids usually grow out of them (commonest in 1-3 year olds)

Beware after a minor head injury a toddler can have one of these, which can be mistaken for being truly knocked out and lead to an unnecessary CT scan.

Question 15

If what you have heard described sounds like a true fit then the commonest 2 types are a ? in a small child, or a non-febrile seizure in a known ? child.

Answer 15

febrile convulsion

epileptic

Question 16

Febrile convulsions

1. usually what kind of seizure?
2. trigger?
3. usual age?
4. duration?
5. T/F: the term implies an innocent seizure

Answer 16

1. are usually generalised, tonic-clonic seizures
2. often happen out of the blue in children with a simple viral infection
3. usual age is 1-3. Careful diagnosing <1 (although do occur). >3 is unusual for a first-time febrile convulsion
4. Most times a febrile convulsion lasts only a few minutes and the child makes a full recovery.
5. false - serious infections such as pneumonia or meningitis can also cause febrile convulsions, so the term does not necessarily imply an innocent seizure. (examine the child properly after the fit and consider bloods)

Question 17

With an ordinary febrile convulsion what is the chance that the child will have another febrile convulsion before they grow out of them?

Answer 17

roughly 50%

• so if it was the first fit, it is important that the parents are given time to calm down, and get some basic medical advice.
• Hospitals often admit a child after their first febrile convulsion.

Question 18

Children with ordinary epilepsy may have a fit triggered by a fever, but we wouldn’t use the term febrile convulsion for these.

Answer 18

ok

However when you see an epileptic child with a fit, you should ask the same questions about infection, so that you don’t miss a treatable cause for the fit.

Question 19

What might suggest hypoglycaemia as the cause of the fit?

Answer 19

is most likely in an infant who has been underfeeding for a couple of days, a child with diabetes, or secondary to severe alcohol poisoning.

Question 20

Describe the typical post-ictal phase in children

Answer 20

• sleepy for about 10 mins- 1 hr
• may have memory loss in this time
• come around > HA, often irritable

NB: if the child became alert and orientated within a minute or two of the so-called fit, it is much more likely to be a non-seizure event.

Question 21

2 broad types of fit?

Answer 21

generalised or focal

Question 22

generalised vs focal seizure? most common?

Answer 22

• Generalised:child is unaware of their surroundings
• Focal: they are awake and the fit is affecting a part of the body

The most typical kind of seizure is called a generalised tonic-clonic seizure.

Question 23

how does a generalised tonic clonic seizure usually present?

(aka a “grand mal seizure”)

Answer 23

• The child becomes unconscious and stiffens (tonic), usually followed by full body jerking (clonic)
• eyes are usually rolled upwards, the jaw and fists clenched, some grunting noises may be heard, and the child may be red or a bit blue in the face. There may be salivation and sweating.

Question 24

what is a petit mal seizure?

Answer 24

an absence seizure - child stops what they’re doing an freezes for a few seconds

Often happens in children with other kinds of fits as well

Question 25

T/F: Focal fits are common

Answer 25

false - uncommon

Focal if only part of the body is affected.

Unusual unless the child is known to have epilepsy or an underlying problem with the brain.

Question 26

If the child is aware of the fit they are called a ____ seizure.

Answer 26

partial

Question 27

the first time a child has a focal fit, most hospitals would arrange what investigation?

Answer 27

CT scan.

Question 28

What to do if a child is having a seizure?

Answer 28

don’t panic!

• Ennsure they’re safely on the ground away from an obstacles. Don’t try to open their mouth
• Note the time
• If longer than 5 mins, give O2. If you have a nasopharyngeal airway and know how to insert it, it may help to hold the airway open. Oropharyngeal, or Guedel, airways are usually impossible to insert because the jaw is clamped shut during a fit
• Drugs to stop the fit (most UK hospitals follow APLS/ EPLS guidelines). It is better to spend a few moments getting IV access and giving a drug slowly and safely, if you are used to doing this. If not, these days the buccal route is becoming more popular than the rectal route and is useful for parents.
• Check a blood sugar on the blood that you obtain when getting intravenous access, or do a heel prick blood glucose.

If the fit persists despite drugs, probs Status Epilepticus.

Question 29

Fits in infants only a few months old often look different from the fits which older children or adults suffer. How?

Answer 29

• The jerking of the limbs and body is less violent and therefore more subtle than older children
• may just go floppy for a few seconds
• They may stare with their eyes rather than the eyes being closed or rolled upwards.

Question 30

T/F: fits in infants are few months old are usually innocent

Answer 30

false - not usually innocent; they need full investigation by a paediatrician.

Question 31

What measures to take in the postictal phase?

Answer 31

• keep them in the recovery position (risk of aspiration as vomiting is common in recovery > only sign in early stages may be slightly reduced O2 sats. May also be raised RR or respiratory distress. Aspiration suspected > admit).
• check blood gucose (3.5-5.5 normal). Treat with glucogel/ IV glucose (hypoglycaemia is an important cause of fits - can cause brain damage if not corrected quickly)

Question 32

potential causes of hypoglycaemia in kids leading to a fit?

Answer 32

• illness e.g. sepsis preceding the fit ad have een eating/ drinking poorly
• may be a diabetic on insulin
• congenital metabolic disease
• alcohol overdose

Question 33

what is status epilepticus?

Answer 33

seizure lasting > 5 minutes or incomplete recovery between fits

risks serious brain damage/ death

Question 34

T/F: status epilepticus usually occurs if a child has known epilepsy or has a serious underlying cause which needs to be treated.

Answer 34

true - although simple febrile convulsions can also present with status epilepticus (minority)

Question 35

status epilepticus management?

Answer 35

Question 36

what are pseudoseizures?

Answer 36

A seizure mimic.

Very uncommon in childhood, usually occurs in those who do have true epilepsy, mid-teens at the youngest.

Very hard to tell- never label an atypical seizure as a pseudoseizure unless this diagnosis has been made by a paediatric neurologist.

Question 37

2 broad types of fit?

Answer 37

Generalised: child is unaware of their surroundings.

Focal: awake and the fit is affecting a part of the body.

Question 38

most typical kind of seizure?

Answer 38

generalised tonic-clonic seizure (aka grand mal)

tonic: child becomes unconscious and stiffens
clonic: followed by full body jerking

eyes are usually rolled upwards, the jaw and fists clenched, some grunting noises may be heard, and the child may be red or a bit blue in the face. There may be salivation and sweating.

Question 39

what is a petit mal?

Answer 39

absence seizure - child stops what they are doing and freezes for a few seconds.

Often happens in children with other kinds of fits as well.

Question 40

T/F: focal fits are common.

Answer 40

false - uncommon

only part of the body is affected.

They are unusual unless the child is known to have epilepsy or an underlying problem with the brain (first focal fit > CT)

Question 41

If the child is aware of the fit they are called a ___ seizure.

Answer 41

partial

Question 42

response if a child is having a fit

Answer 42

• don’t panic!
• Make sure they’re safely on ground, away from any obstacles, and don’t try to open their mouth.
• note the time
• continues beyond 5 minutes:
• call for help.
• give O2 (insert nasopharngeal airawy if possible)
• administer benzos (buccal or IV)
• check blood glucose

Question 43

After a fit children can be drowsy and confused, or agitated. They will have a headache, which contributes to their agitation.

It is important to give them what at this stage?

Answer 43

paracetamol as soon as they are awake enough to take it, or to use a paracetamol suppository instead if they are drowsy.

Question 44

As soon as the fit has stopped you need to examine for which 2 things.

Answer 44

1. serious complications of the fit:
2. cause of the fit in the first place.

Question 45

ABCDENT after a fit?

Answer 45

A: airway obstruction?

B: breathing may be depressed. Place in recovery position.

C: check circulation (fluid loss through sweat during sweat or may be dehydrated from sepsis). HR usually fast initially.

D: AVPU (usually P or U postictal). Full GCS. Pupils (may be small, large or deviated during a fit but shouldn’t be asymmetrical). Check blood glucose.

ENT: useful in febrile convulsion. Temp usually above average postictal due to muscular activity (not usually >38)

Question 46

taking a history - important points to cover DURING the fit?

Answer 46

imp to get eyewitness account, even if this is over the phone,

Question 47

prodromal phase of fits vs faints?

Answer 47

Fits happen without warning, as opposed to faints. They usually last a minute or two. Here is a typical history.

Question 48

Important points to cover for history PRECEDING the fit?

Answer 48

see if you can find a cause

• prexial?

There are many different reasons for a child to experience a fit. Here is a table with the commoner causes of episodes which may be presented as a possible fit. Some of them are and some of them aren’t.

Question 49

what non seizure events may be mistaken for a seizure?

Answer 49

• Faints: may cause a few jerks
• Syncope: drop in blood pressure which causes loss of consciousness. Vasovagal most commonly

Question 50

what faetures of the history may suggest syncope rather than a seizure?

Answer 50

• Usually describes funny vision e.g. tunnel vision or going black, sound becoming distant, and weakness of their legs.
• The recovery phase which is swift compared to a seizure (minute or so)

NB: Incontinence can also happen (more likely if they’re not laid flat, to improve BP)

• Cardiac arrythmia: appearance is the same as a vasovagal faint, although the patient is often described as pale. Often happens out of the blue or on exercise. It is common for the child not to feel any palpitations even when the cause is an arrhythmia.
• vasovagal faints usually happen from about 7 years onwards, not younger children.
• some younger children are prone to an exaggerated vasovagal reaction when they suffer pain or emotion > breath-holding attacks > pallor/ cyanotic. If more severe attack, asystole can occur temporarily and a true seizure can happen, called a reflex anoxic seizure. Totally harmless, children usually grow out of them. They are commonest in the 1-3 year old age group.
• commonest 2 types of fits in a child?
• are a febrile convulsion in a small child, or a non-febrile seizure in a known epileptic child.
• What kind of seizure are febrile convulsions? usually generalised, tonic-clonic seizures, which often happen out of the blue in children with a simple viral infection (1-3 years).
• T/F: febrile convulsion implies an innocent seizure. Not necessarily: most times lasts only a few minutes with full recovery. However beware that serious infections such as pneumonia or meningitis can also cause febrile convulsions.
• chance of recurrence with febrile seizure?
• roughly 50% chance they’ve have another before they grow out of them - so important that the parents are given time to calm down and get some basic medical advice.
• head injury may cause a fit, why is it important to ask specifically about this? Patient/ carer may not bring it up themselves in cases of intoxication induced injury or NAI.
• in what circumstances might hypoglycaemia precipitate a fit? most likely in an infant who has been underfeeding for a couple of days, a child with diabetes, or secondary to severe alcohol poisoning.
• describe the typical postictal phase. Most children are sleepy for 10 mins - 1 hour. May have memory loss. Usually have a HA, so are often irritable. If the child is old enough to tell you they had a headache when they woke up, this is good evidence that it was a true fit. If the child became alert and orientated within a minute or two of the so-called fit, it is much more likely to be a non-seizure event. It is important to examine children properly after a fit. We will explain why in the next section.

Question 51

some younger children are prone to an exaggerated vasovagal reaction when they suffer pain or emotion > what is this called?

Answer 51

breath-holding attacks > pallor/ cyanotic.

In a more severe attack, asystole can occur temporarily and a true seizure can happen, called a reflex anoxic seizure. Totally harmless, children usually grow out of them. They are commonest in the 1-3 year old age group.

Question 52

commonest 2 types of fits in a child?

Answer 52

febrile convulsion in a small child

non-febrile seizure in a known epileptic child.

Question 53

What kind of seizure are febrile convulsions?

Answer 53

usually generalised, tonic-clonic seizures which often happen out of the blue in children with a simple viral infection (1-3 years).

Question 54

T/F: febrile convulsion implies an innocent seizure.

Answer 54

Not necessarily: most times lasts only a few minutes with full recovery. However beware that serious infections such as pneumonia or meningitis can also cause febrile convulsions.

Question 55

chance of recurrence with febrile seizure?

Answer 55

50%

Question 56

why is it important to explicitly ask about head injury in a child presenting with seizure?

Answer 56

patient carer may not volunteer the information readily if:

• caused by intoxication/ drugs
• NAI

Question 57

When might hypoglycaemia present with a fit?

Answer 57

most likely in an infant who has been underfeeding for a couple of days, a child with diabetes, or secondary to severe alcohol poisoning.

Question 58

describe the post-ictal phase of a fit

Answer 58

• sleepy for 10 mins to an hour or so
• memory loss
• HA upon waking is good evident it was a true fit

NB: If the child became alert and orientated within a minute or two, is much more likely to be a non-seizure event.