CASE

PRESENTATION 2
ACLERA, JERCHIE ANTHONY
BATALAO, DANA KAYE
BAHNI, JERAMEEL
GO, JAMIE RONICA
MANONGSONG, MARJORIE
OFTANA, JAZEL
RAGUDO, JOANNE
SALTING, REYGIE
SYGUAN, MICHELLE
YADAV, RAM
BAMUNUGE, DILEEPA

Case 2
Elizabeth J. is a 3 year old with mixed seizures disorder. You
are asked to evaluate her in your clinic. She was a 7 lbs
product of a full term, uncomplicated pregnancy and there
was no pre-natal complication. She developed normally
during her first year. One day, at 18 months, she was noted
to be irritable and anorexic. She developed chronic jerking
on her left arm, lasting for 10 minutes. When her mother
found her temperature to be 103 f rectally. She rushed her
to the hospital. There her focal seizures recurred. It
generalized and persisted until it was terminated with IV
Phenobarbital 23 minutes later.

WAS THIS A FEBRILE SEIZURE?

YES

(+) High Temperature (103 F)-febrile seizure is usually

associated with a core temperature that increases rapidly to
39

Young children (3 mos. to 5 years of age)

Peak age of onset is 1418 months of age

-Febrile seizures are also age dependent and are rare before 9 mos
and after 5 yr of age. The peak age of onset is 1418 months of
age and the patient is 18 months old so she is at the peak of onset
of developing a febrile seizure.

Contd
Usually the seizure lasts for few seconds and rarely up to 15 min
however in the second seizure attack of the patient the duration is
>15 min and she had a repeated convulsions within 24 hours so
the febrile seizure of the patient is described as COMPLEX OR
COMPLICATED FEBRILE SEIZURE.

WHAT OTHER SEIZURE CONTROL

METHODS ARE IMPORTANT IN THIS
CASE?

PRIORITY

Safety ( Airway, Breathing, and Circulation

Assess for the level of consciousness

Observe and examine patient

Obtain blood: anticonvulsant level, toxicology screen

Analyzing the detailed Clinical History

Routine management of a normal infant with febrile convulsions includes a careful

search for the cause of the fever and reassurance and education of the parents.

ANTIPYRETICS - active measures to control the fever, to prevent seizure

recurrences.

VENTILATION

ANTI SEIZURE DRUGS -Phenobarbital, oral diazepam may be used as an

effective and safe method of reducing the risk of recurrence of febrile seizures.

WHAT WAS MANDATORY IN

THIS WORK UP?

Serum levels of anticonvulsant agents to determine baseline

levels, potential toxicity, lack of efficacy and treatment
noncompliance.

Checking of the patients temperature and giving Phenobarbital IV

to terminate the convulsion.

Serum glucose should be evaluated with the 1st afebrile seizure.

Continuation-Elizabeth was well controlled on

Phenobarbital until age 22, when she developed
weekly starting spells of 1-2 minutes duration
4.HOW WOULD YOU MANAGE HER THERAPY ?

The goal of treatment is to achieve a seizure-free status without

adverse effects. Monotherapy is important, because it decreases
the likelihood of adverse effects and avoid drug interaction.

Standard of care for a single, unprovoked seizure is avoidance of

typical precipitants considering the factors (age of onset and
current condition).

At 3 years, the starting spells returned. In addition,

she had extensor spasm (3-4 seconds duration) that
occur twice a week.

5.WOULD YOU ADMIT HER FOR FURTHER EVALUATION ?

Yes, a careful history is warranted to ascertain a potential family history

of epilepsy, a prior neurologic disorder, or history of seizure with fever,
which may increase the likelihood of recurrence.

Important diagnostic work ups;

EEG

indicated in all cases of epilepsy and is useful for determining the type
of epilepsy and the future prognosis.

it is useful for diagnosis of the event, prediction of recurrence risk, and

identification of specific focal abnormalities and/or epileptic syndromes.

LUMBAR PUNCTURE-should be considered for children with repeated

seizures and other evidence of neurodevelopment disability.

Contd

LOW CSF GLUCOSE -glucose transporter disorder; alterations in

amino acids, neurotransmitters, or cofactors in metabolic
disorders; or evidence of chronic infection

NEUROIMAGING-MRI is indicated during the evaluation of

children with newly diagnosed epilepsy, especially for those with
neurologic deficits, partial seizures, or focal EEG abnormalities
that are not part of an idiopathic localization-related epilepsy
syndrome.

6.WHAT INDICATION WOULD

YOU CONSIDER?

Non pharmacologic therapy:

Vagal Nerve Stimulation

It involves implanting apacemaker-like device that generates pulses of electricity to

stimulate the vagus nerve.

Pharmacologic therapy:

Selection of an anticonvulsant medication

The use of phenobarbital (5 to 8 mg per kg of weight per day for children

two to 24 months of age, and 3 to 5 mg per kg per day for children older
than two years) and valproic acid (10 to 15 mg per kg per day in divided
doses, with a maximal dosage of 60 mg per kg per day) on a continuous
basis reduces the risk of recurrent febrile seizures but has significant side effects.
Phenobarbital is associated with transient sleep disturbances, decreased memory,
and reduced concentration. Valproic acid therapy is associated with hematopoietic
disruptions, renal toxicity, pancreatitis, and fatal hepatotoxicity.

Contd

The use of intermittent oral diazepam also has been found to reduce the risk of
recurrent febrile seizures, but the effectiveness is limited. Hyperactivity was the
most common side effect in the oral diazepam group, and other side effects
included lethargy, ataxia, and drowsiness.

For patients who have an ongoing seizure at the time of assessment, intravenous
diazepam (0.2 to 0.5 mg per kg of weight intravenously every 15 minutes
for a cumulative dosage of 5 mg in children one month to five years of
age) often is effective.

For the pre-hospital treatment of a seizure or for patients in whom intravenous

access is limited, rectal diazepam (a single dose of 0.5 mg per kg for children
two to five years of age) or diazepam gel is an option.

Lorazepam (0.1 mg per kg up to 4 mg) is another intravenous medication, and

it has a longer duration of action compared with diazepam.

Surgical Options:

Use of a Vagal Nerve Stimulator (VNS) for palliative therapy.