CH WK4 CASE 1

 Children’s Health – Suspected seizure

Luke is a 2 year old with developmental delay, presenting to A&E with an unresponsive shaking episode.

Suspected seizure ILOs

Guidance and Resources – Suspected seizure

In case Children’s Health – Suspected seizure

Guidance

This case initiates the theme of recognizing and managing a child with altered consciousness and with a suspected seizure. As you work through the case, you need to learn:

· Patient with altered consciousness

· How to evaluate of a patient with altered consciousness

· What is the difference in a children’s Glasgow Coma Score

· Seizure and epilepsy

· To give a definition for a seizure and epilepsy and how to diagnose epilepsy.

· How to take a relevant history for a child with a seizure.

· To interpret relevant examination and investigative results to consider the differential causes for a young child with a seizure

· Treatment of epilepsy.

· Developmental delay

· How to take a history relevant to a child with developmental delay

· To provide a differential diagnosis for gross motor delay in children

· To give a definition for cerebral palsy and list possible etiological causes.

eBooks

Illustrated Textbook of Paediatrics 4th edition. Lissauer (Mosby Elsevier)

Textbooks

Advanced Paediatric Life Support: the practical approach to emergencies. Martin Samuels & Susan Wieteska (Chapters 8 & 9)

Nelson Essentials of Pediatrics:, Karen Marcdante MD, Robert M. Kliegman MD

Web Links

Fits, faints and funny turns in children – Australian Family Physician Vol. 34, No. 12, December 2005

Epilepsies: diagnosis and management – Clinical guideline [CG137]

The management of children and young people with an acute decrease in conscious level – RCPCH

Status Epilepticus – APLS

International League Against Epilepsy

British Paediatric Neurology Association

CASE COMPONENT

Case Introduction – Suspected seizure 

Please take time to read this National guideline developed in Nottingham on managing an unconscious child (2008):

· The Management of a Child (aged 0-18 years) with a Decreased Conscious Level – The Paediatric Accident and Emergency Research Group

RCPCH national guideline on the management of children and young people with an acute decreased conscious level (2015) is an indepth review of the original guideline:

· The management of children and young people with an acute decrease in conscious level – RCPCH

History from a reliable witness is the key to diagnosis of a child with seizure (and altered consciousness).

Further Case Information – Suspected seizure

In case Children’s Health – Suspected seizure

Here is what you found out about Luke that you presented to Dr James ST4:
He was well recently and was himself. He has a viral cold but no fever. There was no history of head injury, ingestion, vomiting or choking. He was sat on a baby high chair waiting his breakfast when his mum witnessed Luke suddenly looking up and towards his left side. His body stiffened asymmetrically with extension of his left arm and legs before his whole body and 4 limbs jerked rhythmically. During this event Luke’s face twitched with the body. He had blue lips and abnormal gurgling breathing efforts. His eyes rolled upwards and he was not responsive. The Jerking continued for 7 minutes but stopped gradually after 2minutes of receiving rectal diazepam by the paramedics. Luke then fell into a deep sleep-like state afterwards and did not flinch when a finger prick sugar test was carried out. He remained is this state until he woke up during the consultation in A&E. He was upset and disorientated initially but within 15 minutes was back to himself fully. He did not have urinary incontinence and has no injuries.

Relevant Background history

Luke was born by emergency caesarean section at 37+2 for foetal distress.

Luke had a left focal febrile seizure 12 months ago. It was with a definite febrile respiratory illness. Lasting 10 minutes, it stopped before paramedics arrived.

What is a seizure? What is epilepsy?

An epileptic seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.

Regarding Luke’s seizure and drowsy state, he recovered fully an hour after the seizure and was observed overnight. His observations overnight were stable. He woke up himself and had breakfast. The parents were visibly upset about the events they witnessed.

You examined Luke as he is fully awake and recovered from his seizure. You found that he has more brisk tendon reflexes to his left knee and ankle. He has up going plantar reflex with some ankle clonus of the left foot. He had similar antigravity movements of his legs and gait.

Luke has left sided upper motor neurone lesion signs. This might correspond to his afebrile seizure, which had some possible left sided focal features. This would also match his previous left sided febrile seizure. You query if there is structural brain abnormality as an underlying cause for this. You have discussed with Dr James your findings and this information was shared the next day at the Consultant ward round. The Consultant, Dr Ward, found the same neurology signs. Luke seemed to have very mild left sided out swinging of his leg and toe strike when he ran. This is therefore not just a post-seizural phenomenon. This focal neurology is likely longstanding. The diagnosis is likely cerebral palsy.

                   CT                                                                                                    MRI

very high radiation dosage and should be avoided

 for elective imaging, unless an MRI is not available

                                                                                                 takes longer than a CT scan, then it needs to be done under sedation or even sometimes                                                                                                               under general anaesthetic.

                                                                                               An elective brain MRI scan is also preferred as it would detect subtle changes a CT might miss

Background Science – Suspected seizure

In case Children’s Health – Suspected seizure

Here is some useful background on the pathophysiology of seizures:

CASE COMPONENT

Case Conclusion – Suspected seizure

In case Children’s Health – Suspected seizure

Luke had an MRI brain scan 2 weeks later:

The report was shared with the family in the clinic. It showed right encephalomalacia with evidence of an old cerebral infarction to the distribution of the right middle cerebral artery with right sided cerebral atrophy and ventriculomegaly present. The family was counselled on the diagnosis that Luke has mild cerebral palsy due to this brain injury that had occurred, most likely in-utero. Often a stroke before birth, does not reccur and further investigation will very unlikely yield a causation.

The family were further counselled that:

Luke’s mild weakness should not worsen.

A referral to community paediatric team to further assess and manage Luke is required.

A referral to the physiotherapist was also made.

They were also counselled regarding epilepsy risk, which is a significantly higher with these MRI changes and given Luke’s focal febrile and then afebrile seizure.

Equipped with the prognosis, the family choose to ‘wait and see’ and this is supported by their Consultant. A plan of ‘what if’ Luke had another afrebile seizure was made. An EEG was not requested at this stage. Their Consultant arranged for a second opinion regarding the neuroimaging and clinical situation with a local pediatric neurologist and follow-up.

https://youtu.be/ZBGN90ctY8U

Formative Assessment – Suspected seizure