S EIZURE RECOGNITION , SEIZURE
TYPES , F IRST A ID AND S AFETY
Charuta Joshi MBBS, FRCPC
Director of pediatric epilepsy
UIHC

At the end of this lecture the participants will be able to:
Define a seizure
Recognize different types of seizures
Define epilepsy
Know basic steps involved in seizure first aid
Name 2 different medications used on the site to treat seizures in the prehospital setting
Be familiar with ketogenic diet as therapy for seizures

What is a seizure
Seizure recognition
• A clinical manifestation of :
• Abnormal
• Excessive
• Paroxysmal
• Electrical discharge in neurons

• Stereotyped
• Repetitive
• If unsure video tape events
• Ask pediatrician to see

• Spectrum of findings
Complex partial seizures
Generalized seizures
Simple partial seizures

Seizure recognition simple partial seizures
• Localization

Seizure recognition
Generalized
• Absence
• Myoclonic
• Tonic
• Generalized tonic clonic

How important is it to be sure about a seizure

• 127 children
• 94 were given diagnosis of epilepsy in first seizure clinic
• 36 had suffered at least one previous seizure
( 15 unrecognized by family as a seizure)
• 31 – non epileptic events
• Unclassified in 2

Investigations after a first unprovoked seizure

Yield of neuroimaging
(Shinnar et al 2001)

• Tendency to have recurrent, unprovoked seizures
• 2 or more unprovoked seizures separated by
24 hours

Questions parents have after seizures
• Will it happen again ?
• How long do I have to wait for a recurrence ?
• Could my child die during a recurrence?
• Could there be brain damage due to recurrence
• If medication treatment is delayed will there be change in long-term chance of permanent remission?

• Recurrence rate at 2 years 40-50%
• Half the recurrences are within 6 months of initial seizure
• 80% of 5 year recurrence risk stabilizes by 2 years out

• Remote symptomatic etiology
• Abnormal EEG ( any spikes, generalized spike wave, focal or generalized slowing)
• Occurrence of seizure during sleep state (increases chance of recurrence)= lower morbidity than during daytime seizure
• Risk of recurrence after 2 seizures is 80%

• Treatment reduces the risk of a second seizure by 50% at 2 years
• Immediate treatment DOES NOT reduce risk of long term seizures
• Treated and untreated groups have a 64% chance of 5 year remission at 10 years (MESS study)
• Risk of toxicity, allergic reaction, cognitive side effects

Risks of morbidity/ mortality due to seizures- could my child die??
• 692 children in Nova Scotia ( Camfield 2002)
• Followed =20 years
• 26 deaths
• 1 from status
• 1 from SUDEP as an adult at age 22 years

• Dutch study of childhood epilepsy ( Callenbach 2001)
• 472 children followed for 5 years
• 9 deaths
• None from epilepsy
• Connecticut study ( Berg 2004)
• 613 children followed for 7.8 years
• 13 deaths
• 1=status
• 1=SUDEP

When does immediate treatment matter
• When risks of recurrent seizures outweigh benefits of withholding treatment ( adults)
• Cyanotic congenital heart disease in a child

• ABCs
• Stay calm
• Don’t leave patient alone
• Lateral position if possible
• Don’t restrain
• Nothing in mouth
• Call 911

• Maximize quality of life
• Water safety
• Safety on roads
• High structures
• Medic alert, seizure beds, seizure dogs, baby monitors

• Regular sleep
• Alcohol
• Infections
• Photic stimulation
• Substances of abuse
Sports participation has not been shown to increase risk of seizures

Operational definition of status
0
Most seizures stop
5
Optimum time to start therapy
15
Time definition of convulsive status epilepticus
30

Medications used for prehospital treatment
• Diazepam
• Midazolam
• Lorazepam

• 2mg/ml Intensol
• Indicated for anxiety

Moving on to a different discussion now…

• UIHC= The only center in the state
• 30-40 active patients
• Dedicated dietician
Karla Mracek
• Dedicated ARNP
Tiffany Rickertsen

History
• Mac Fadden 1899- magazine
Physical Culture
• Medical profession= Organized fraud
• People who follow MacFadden’s rules would live to 120 years
• Since much of the body’s energy is wasted in digesting food, if no food is provided, more energy can be applied to recovering health
• Dr Conklin-osteopath in
Battlecreek , Mi
• Used diet in epilepsy
Mr MacFadden
• Physical culture

• Conklin’s work( intestinal epilepsy- toxin release from glands= seizures)
• Conklin’s fast 18-21 days ( or as long as they could stand it)

• Dr Geyelin worked at Johns Hopkins= confirmed Conklin's findings
• Dr BJ Wilder= fat can be used to break fast= no seizures

Charlie Foundation
• Mr Jim Abrahams
• Sought help from Johns
Hopkins for his son Charlie
• Seizure free today after several medications and neurologists
Movie

Mechanisms of action
Not exactly known
• Ketone bodies= antiepilepsy properties
• PUFAs= membrane stabilization
• Antioxidative/ antiinflammatory
• Uncoupling of oxidative phosphorylation( better energy utilization)

• Classic ketogenic diet= 4:1 ratio
• MCT oil diet ( less restrictive)
• Modified Atkins diet=15-20 gm carbs/day
• Low Glycemic index diet=60 gm carbs/day

Most kids not fat… Results
• 50-60% improve
• Almost 100% improve –
Doose , GLUT1
Contraindicated
Fatty acid oxidation defect