CASE PRESENTATION
PRESENTED BY : DR OSAMA SHABBIR
SUPERVISED BY : DR PAHLAJ KOLHI
HISTORY
• 4 DAYS OLD, MALE BABY BORN AT 40 WEEKS GESTATION AND DELIVERED VIA
NORMAL VAGINAL DELIVERY AT SWAT MEDICAL CENTER WEIGHING 3.2 KGS,
PRESENTED WITH COMPLAINTS OF ;
• HIGH GRADE FEVER } SINCE 3 DAYS
• INABILITY TO FEED } SINCE 2 DAYS
• EXCESSIVE CRY } SINCE 1 DAY
HISTORY OF PRESENTING COMPLAIN:
• ACCORDING TO THE MOTHER THE BABY WAS BORN HEALTHY AND NORMAL AND
DISCHARGED FROM SWAT MEDICAL CENTER WITHIN 3HOURS OF BIRTH. HOWEVER ON THE
2ND DAY OF LIFE THE MOTHER NOTICED THE BABY DEVELOPED SOME FEVER FOR WHICH
THE BABY WAS GIVEN A BATH BY HIS GRANDMOTHER. THE BABYS CONDITION
WORSENED AFTERWARDS AND HE DEVELOPED HIGH GRADE FEVER WHICH WAS SUDDEN
ONSET AND CONTINUOUS. IT WAS UNDOCUMENTED AND NOT ASSOCIATED WITH RIGORS
OR CHILLS. THERE WAS 1 EPISODE OF VOMITING WHICH WAS SCANT, NON BLOODY AND
HAD MILK CONTENT. THERE WAS 1 EPISODE OF FITS WHICH THE MOTHER DESCRIBED AS
BRIEF STIFFENING OF THE BODY WITH EYE ROLLING. THERE WAS NO DIARRHEA OR
CONSTIPATION. THE MOTHER WENT TO A LOCAL NEARBY CLINIC WHERE SHE WAS GIVEN
ANTIPYRETIC BUT THE FEVER WAS NOT RELIEVED.
• THE BABY SOON DEVELOPED RELUCTANCE TO FEED THE NEXT DAY AND WAS NOT
TAKING ANY MILK. EXCESSIVE LOUD CRY DEVELOPED SINCE YESTERDAY WHICH
COMPELLED THE MOTHER TO BRING THE BABY TO PAEDS 3 NURSERY AT CHK.
BIRTH HISTORY
• ANTENATAL: IT WAS A BOOKED CASE AT SWAT MEDICAL CENTER, KARACHI. 2 ANTENATAL
SCANS WERE DONE AT 5TH AND 8TH MONTHS. TETANUS TOXOID INJECTION AND
MULTIVITAMINS WERE NOT TAKEN. THE MOTHER HAD BURNING MICTURITION FOR 2 WEEKS
IN HER LAST MONTH OF PREGNANCY WITH FEVER. THERE WAS NO HISTORY OF GDM, PIH,
ECLAMPSIA AND RASH. THERE WAS NO HISTORY OF ANY PREMATURE RUPTURE OF
MEMBRANES.
• NATAL HISTORY: THE BABY WAS BORN AT 40 WEEKS IN SWAT MEDICAL CENTER VIA NVD
WEIGHING 3.2KGS. THERE IS NO HISTORY OF ANY TRAUMA TO BABY DURING BIRTH.
POST NATAL HISTORY: THE BABY CRIED IMMEDIATELY. THERE WAS NO HISTORY OF
DELAYED CRY OR CYANOSIS. NO RESUSCITATION HISTORY OR MECONIUM ASPIRATION. THE
VITAMIN K WAS GIVEN. THE APGAR SCORES ARE UNKNOWN.
• FEEDING HISTORY: THE BABY HAD HIS FIRST DIRECT MOTHER FEED AFTER 2 TO 3
HOURS OF BIRTH AND HAD 4 TO 6 FEEDS ON FIRST DAY. THE BABY DEVELOPED
DECREASED FEED FROM 2ND D TO AFTERWARDS AND NOW RELUCTANCE TO FEED.
• IMMUNIZATION HISTORY: NO VACCINATION YET.
• FAMILY HISTORY:
2ND PRODUCT OF NON CONSANGUINEOUS MARRIAGE.
THERE IS NO HISTORY OF ANY ACUTE OR CHRONIC ILLNESS IN THE FAMILY EXCEPT FOR
HYPERTENSION AND DIABETES IN MATERNAL GRANDMOTHER.
THE BABY HAS A 5YRS OLDER SISTER WHO IS HEALTHY AND ALIVE.
• SOCIOECONOMIC HISTORY:
THE FATHER IS A RIKHSHAW DRIVER
THERE ARE 12 PEOPLE LIVING IN A RENTED APARTMENT.
TAP WATER IS USED FOR DRINKING
OVERALL STATUS IS POOR
GENERAL PHYSICAL EXAMINATION:
• OVERALL A VERY IRRITABLE AND SICK BABY PRESENTED IN THE NURSERY OPD. THE PATIENT HAD ACTIVE
STARY GAZE WITH ARCHING.
• VITALS:
HEART RATE – 140 BPM
RESPIRATORY RATE – 62 BPM
SAO2 – 99% ON ROOM AIR
TEMPERATURE – 103 * F (39.4*C)
RANDOM BLOOD SUGAR – 64MG/DL
A- , E- , D- , CY- , J-
• ANTHROPOMETRY :
WEIGHT 3.2 KGS
LENGTH 49 CM
OFC 35 CM
HEAD TO TOE EXAMINATION:
• ANTERIOR FONTANELLE OPEN AND FULL.
• NO HEAD SWELLING, CAPUT OR CEPHALHEMATOMA
• HEENT: NORMAL
• NO CLEFT LIP OR PALATE.
• BACK AND SPINE: NORMAL
• UMBILICUS: CENTRAL , DRY AND CLAMPED.
• LIMBS: NORMAL AND SYMMETRICAL
• GENITALIA: MALE (TESTED DESCENDED)
• ANUS: PATENT
SYSTEMIC EXAMINATION:
• CHEST EXAMINATION:
ON INSPECTION THE CHILD HAD A SYMMETRICAL CHEST WITH NO VISIBLE DEFORMITY ,
BULGING OR SCAR MARKS PRESENT. A BILATERALLY EQUAL MOVING CHEST WAS NOTED
WITH SC, IC RECESSIONS WITH NASAL FLARING.
ON PALPATION THE TRACHEA WAS CENTRALLY PLACED.
ON PERCUSSION THERE WAS A BILATERAL RESONANT NOTE.
ON AUSCULTATION THERE WAS BILATERAL NORMAL VESICULAR BREATHING PATTERN,
BILATERALLY EQUAL AIR ENTRY WITHOUT ANY CREPT, WHEEZES OR OTHER ADDED
SOUNDS.
SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
ON INSPECTION THERE WAS NO DEFORMITY NOTICED. THE UMBILICUS WAS NOTED TO BE CENTRALLY
PLACED AND NO VISIBLE PULSATIONS OR MARKS WERE PRESENT. ON SOFT PALPATION THERE WAS NO
TENDERNESS, AND IT WAS GENERALLY SOFT AND NONDISTENDED. ON DEEP PALPATION THERE WAS
NO VISCEROMEGALY. THE GUT SOUNDS WERE AUDIBLE ON AUSCULATATION.
CARDIOVASCULAR EXAMINATION:
ON INSPECTION, NO VISIBLE BULGE, PROMINENT VEINS OR PULSATIONS SEEN. THE APEX BEAT WAS
PALPATED TO BE IN THE 4TH LEFT INTERCOSTAL SPACE MEDIAL TO MID CLAVICULAR LINE. THE
CAPILLARY REFILL TIME WAS <2SECONDS AND THE PERIPHERAL PULSES WERE GOOD. ON
AUSCULTATION BOTH S1 AND S2 WERE NOTED NORMALLY WITHOUT ANY ADDED MURMURS OR
GALLOP.
SYSTEMIC EXAMINATION:
• CENTRAL NERVOUS EXAMINATION:
THE BABY PRESENTED WITH A INCREASED TONE AND POSTURE. THE ANTERIOR
FONTANELLE WAS BULGING. FOLLOWING REFLEXES WERE ALSO SEEN:
MORO – INCOMPLETE
SUCK – POOR
GRASP – FAIR
ROOT – POOR
BOTH THE PUPILS WERE EQUALLY REACTIVE TO LIGHT. THE GCS WAS 15/15
CASE SUMMARY
• A 4 DAY OLD MALE BABY BORN AT TERM VIA NORMAL VAGINAL DELIVERY WEIGHING
3.2KGS CAME WITH PRESENTING COMPLAINTS OF HIGH GRADE FEVER, RELUCTANCE TO
FEED AND EXCESSIVE CRY. THE BABY DEVELOPED FEVER SINCE 3DAYS, UNDOCUMENTED
AND NOT ASSOCIATED WITH ANY RIGORS CHILLS, DIARRHEA OR CONSTIPATION AND NOT
RELIEVED BY ANY ANTIPYRETICS. THERE WAS 1 EPISODE OF VOMITING AND FITS ON 2ND
DOL. HE ALSO HAD DECREASED FREQUENCY OF MOTHER FEED STARTING 2DOL AND NOW
RELUCTANCE TO FEED AND THERE IS ALSO EXCESSIVE CRY THROUGHOUT THE DAY.
• ON EXAMINATION, A SICK LOOKING CHILD WITH IRRITABILITY AND HIGH PITCHED CRY
WAS NOTICED WITH FULL FONTANELLE. THE RESPIRATORY, ABDOMINAL,
CARDIOVASCULAR SYSTEMS WERE UNREMARKABLE. HOWEVER TONE WAS INCREASED
AND REFLEXES WERE POOR ON CNS EXAM.
DIAGNOSIS?? DIFFERENTIALS ?
• 1. EARLY ONSET MENINGITIS
• 2. EARLY ONSET SEPSIS
TREATMENT ON ADMISSION:
• THE PATIENT WAS KEPT NPO TILL FURTHER ORDER.
• OXYGEN VIA CPAP AT 6/6 CM OF H2O
• INJECTION 0.45 D/S + 10% DW WERE GIVEN ABOUT 370ML I/V OVER 24 HOURS WHICH INCLUDED THE 20%
EXTRA FLUID.
• INJECTION DIAZEPAM 0.6MG I/V X STAT
• INJECTION PARACETAMOL 3.2ML I/V X STAT
• ANTIBIOTICS:
1. AMIKACIN – 48MG I/V X OD (DILUTED IN 10CC N/S)
2. CEFOTAXIME – 320MG I/V X BD (DILUTED IN 20CC N/S)
• FOLLOWING LAB TESTS WERE SENT: CBC, BLG, CRP, UCE, MG, CAL, PHOS, TOTAL PROTEIN AND AG RATIO,
BTD, PT, APTT, BLOOD CS, URINE CS AND DR.
• LP WAS ALSO PLANNED.
• DR ON DUTY WAS ADVISED TO WATCH FOR ANY FITS, RESPIRATORY DISTRESS, PULSE, ANY VOMITING
AND FEVER WAS TO BE DOCUMENTED AND CHARTED.
INVESTIGATIONS (HEMATOLOGY)
Lab/Date 24/11 25/11 26/11 28/11 29/11 1/12 2/12 4/12
HB 15.8 15.0 14.9 12.9 12.8 15.2 13.0
HCT 49.30 45.2 48.2 40.90 39.2 46.10 39.00
MCV 106.7 100.2 99.6 103 101.6 99.8 99.7
MCH 34.2 33.3 30.8 32.7 33.2 32.9 33.2
MCHC 32 33.2 30.9 31.5 32.7 33.0 33.3
TLC 13.4 6.8 9.7 5.7 5.4 7.2 7.3
Neutros 70% 74.6% 64% 61.7% 41.1% 30% 32%
Lymphos 16% 19 26% 30% 38% 45% 58%
Eosino 5% 3% 2% 5% 2% 5% 4%
Mono 9% 6% 8% 4% 19% 20% 6%
Platelets 262 57 47 34 22 38 85
CRP 5.3 93.2 131.1 131.5 32.2
PT 21 14.1
APTT 28.3 27
INR 2.0 1.35
INVESTIGATIONS (BIOCHEMISTRY)
Lab/Date 24/11 25/11 26/11 28/11 29/11 1/12 4/12
BUN 16 22 21 hemolysed 7 8 6
Creat 0.9 0.6 0.5 0.2 0.1 0.1
Na 151 140 134 134 137 135
K 5.4 4.1 3.0 3.8 4.0 4.6
Cl 111 102 97 101 103 102
Cal 8.7
Mg 2.3
Phos 5.2
INVESTIGATIONS (LFTS + MISC)
Lab/Date 24/11
Total Bili 5.2
Direct 0.5
Indirect 4.7
Total Protein 6.2
Albumin 3.7
Globulin 2.5
A/G Ratio 1.48
BLOOD CULTURES
• BLOOD CULTURE DONE ON 24/11/21
NO BACTERIAL GROWTH SEEN AFTER 5 DAYS OF INCUBATIONAT 37*C UNDER AEROBIC
CONDITIONS
• BLOOD CULTURE DONE ON 29/11/21
GROWTH OF BURKHOLDERIA CEPACIA. SENSITIVE TO CEFTAZIDIME, LEVOFLOXACIN,
MEROPENEM, SULPHAMETHAXAZOLE/TRIMETHOPRIM. RESISTANT TO POLYMIXIN-B
• BLOOD CULTURE DONE ON 1/12/21
BURKHOLDERIA CEPACIAN. SENSITIVE TO SAME 4 ANTIBIOTICS.
URINE REPORT & CULTURES
• URINE DR REPORT ON 24/11/21:
PH : 6.0
SPECIFIC GRAVITY: 1.015
COLOR: DARK YELLOW
QUANTITY: 25ML
PROTEIN: +
GLUCOSE: +++
AMORPHOUS URATE: +
RED CELLS: 1.2/HPF
PUS CELLS: 2.3/HPF
EVERYTHING ELSE: NIL
• URINE CULTURE REPORT ON 24TH/11/21
NO GROWTH
LUMBER PUNCTURE
• LP: WAS PLANNED AND THE PARENTS WERE COUNCELLED BUT THEY REFUSED FOR LP.
TREATMENT DURING HOSPITAL
• OXYGEN TAPERED OFF ON PRONGS ON THE FIRST DAY OF ADMISSION. INJ 0.45 DS WITH
10% DW WAS GIVEN. ANTIBIOTICS CEFITAXIME AND AMIKACIN WERE STARTED AND 32ML
FFP WERE TO BE TRANSFUSED X BD
• ON 2ND DAY OF ADMISSION, NG FEED TRIAL WAS STARTED WITH PATIENT ON FREE FLOW
OXYGEN. FLUIDS AND ANTIBIOTICS . INJ PROVAS WAS GIVEN 3.5CC I/V SOS. 1 FFP WAS
TRANSFUSED AND INJ VITAMIN K 2MG I/V X OD WAS GIVEN. INJ PHENYTOIN WAS LOADED
20MG/KG AND THEN MAINTENANCE DOSE WAS ADDED AT 5MG/KG/DAY IN TWO DIVIDED
DOSES.
• ON 3RD DOA, ROUTINE TREATMENT WAS CONTINUED IN WHICH FLUID WAS INCREASED
ACCORDING TO DOL. IN THE EVENING AND OG FEED 10CC 8HRLY WAS STARTED WHICH
WAS WELL TOLERATED.
COURSE DURING HOSPITAL STAY
• ON 4TH DOA, OG FEED INCREASED TO 15CC, FREE FLOW, FLUIDS AND PHENO WERE CONTINUED.
ANTIBIOTICS LEVOFLOXACIN 32MG IV 12HRLY AND INJ MEROPENEM 130MG IV DILUTED IN 30CC
0.45DS 8HRLY WERE STARTED AFTER POSITIVE GROWTH OF BURKHOLDERIA WAS SEEN IN BCS.
• ON 5TH DOA THE BABY WAS SHIFTED TO DIRECT MOTHER FEED AND ROUTINE TREATMENT WAS
CONTINUED WITH THE BABY ON ROOM AIR NOW. 2CC KCL WAS ADDED IN 100CCML FLUIDS
ONCE IN 24HRS. INJ PHENYTOIN WAS STOPPED AND TABLET PHENOBARBITAL 15MG (½) X HS WAS
ADDED AND PT WAS WATCHED FOR FITS. THE PATIENT HAD A FEVER SPIKE AND PARACETAMOL
WAS GIVEN. 32ML OF PLATELETS WERE TRANSFUSED IV UNDER COVER OF LASIX.
• ON 6TH DOA, BABY WAS IMPROVING WITH THE ROUTINE TREATMENT SO WAS SHIFTED TO POST
NURSERY WITH DR ADVISED TO WATCH FOR BLEEDING, FITS, FEVER SPIKES. THERE WERE NO
EPISODES OF FITS DURING THE CARE IN POST NURSERY AND NO SUDDEN INCREASE IN OFC.
• AFTER SPENDING 5 DAYS IN THE POST NURSERY, THE BABY WAS DOING WELL SO WAS
DISCHARGED HOME WITH ANTIBIOTIC (ORAL LEVOFLOXACIN), TAB PHENOBARB AND VITAMIN
SUPPLEMENTS. PATIENT WAS ADVISED TO FOLLOWUP.
TOPIC OF DISCUSSION : SEIZURES IN NEONATES
• SEIZURES:
CLINICALLY DEFINED AS A PAROXYSMAL ALTERATION IN NEUROLOGIC FUNCTION (BEHAVIOURAL,
MOTOR OR AUTONOMIC FUNCTIONS.
INCIDENCE: NEONATAL SEIZURES ARE RELATIVELY COMMON AND OCCUR IN 0.15 TO 1.5% OF ALL
NEONATES.
PATHOPHYSIOLOGY?
NORMALLY NEURONS UNDERGO DEPOLARIZATION (NA+ INFLUX IN CELLS) AND REPOLARIZATION
(EFFLUX OF K+). A SEIZURE OCCURS WHEN THERE IS INCREASED SYNCHRONOUS ELECTRICAL
DISCHARGE DUE TO EXCESSIVE DEPOLARIZATION. REASON?
1. FAILURE OF SODIUM POTASSIUM PUMP (DISTURBANCE IN ENERGY PRODUCTION)
2. RELATIVE EXCESS OF EXCITATORY VS INHIBITORY NEUROTRANSMITTER
3. RELATIVE DECREASE IN INHIBITORY VS EXCITATORY NEUROTRANSMITTER
4. ALTERATION IN NEURONAL MEMBRANE CAUSING INHIBITION OF NA+ MOVEMENT.
HOWEVER BASIC MECHANISM OF NEONATAL SEIZURES IS UNKNOWN.
CAUSES:
• 1. PERINATAL ASPHYXIA: MOST COMMON CAUSE. OCCUR IN FIRST 24HRS OF LIFE. CAN
PROGRESS TO STATUS EPILEPTICUS.
PREMIES-> GENERALISED TONIC TYPE TERM-> MULTIFOCAL CLONAL TYPE
• INTRACRANIAL HAEMORRHAGE: ANY HYPOXIC INSULTS RESULTING IN EITHER
SUBARACHNOID, PERIVENTRICULAR OR INTRAVENTRICULAR HEMORRHAGE.
SAH-> 2ND POSTNATAL DAY SEIZURES, INFANT APPEARS WELL DURING INTERICTAL PHASE
INTRAVENTRICULAR-> GENERALIZED TONIC SEIZURES
SUBDURAL-> FOCAL SEIZURES
• METABOLIC ABNORMALITIES: HYPOGLYCEMIA (IDM ESPECIALLY), HYPOCALCEMIA (LBW
INFANTS, HYPERPARATHYROID MOTHERS), ELECTROLYTE DISTURBANCES (IMPROPER FLUID
MANAGEMENT), AMINO ACID DISORDERS (HYPERAMMONEMIA AND ACIDOSIS), PYRIDOXINE
DEPENDENCY. (RESISTANT TO ANTICONVULSANTS, RESEMBLE ASPHYXIATED INFANTS WITH
MECONIUM STAINING)
• CONGENITAL MALFORMATIONS OR BRAIN DEFECTS
• INFECTIONS: BACTERIAL MENINGITIS (GROUP B STREPTOCOCCI, ECOLI, LISTERIA IN FIRST
WEEK OF LIFE)
OTHER NON BACTERIAL ? TOXOPLASMOSIS, HSV, CMV, RUBELLA, AMEBIA
• DRUG WITHDRAWAL SUCH AS:
ANALGESICS, SEDATIVES, ALCOHOL, ANTIDEPRESSANTS
• TOXIN EXPOSURE (LOCAL ANESTHETICS GIVEN AT TIME OF BIRTH – GENERALISED TONIC
CLONIC SEIZURE)
• MISCELLANEOUS? ZELLWEGER SYNDROME, TUBEROUS SCLEROSIS, BENIGN IDIOPATHIC
NEONATAL SEIZURES (FIFTH DAY FITS), STARTLE DISEASE, CONGENITAL HYPOTHYROIDISM.
• RISK FACTORS?
1. PREMATURITY 4. MATERNAL DM & INCREASED AGE
2. LOW BIRTH WEIGHT 5. INTRAPARTUM FEVER/INFECTION
3. DELIVERY >42WKS 6. TRAUMATIC DELIVERY
TYPES OF SEIZURES?
4 MAIN TYPES:
1. SUBTLE SEIZURES: SEEN MOSTLY IN PRETERM BABIES.
HAVE TONIC HORIZONTAL DEVIATION OF EYES WITH OR WITHOUT JERKING, EYE FLICKERING, SUCKING
OR DROOLING. SOME INFANTS ALSO HAVE APNEIC SPELLS.
2. CLONIC SEIZURES: MOSTLY IN FULLTERMS. 2 TYPES:
FOCAL -> WELL LOCALIZED, RHYTHMIC AND SLOW JERKING MOVEMENTS INVOLVING FACE OR LIMBS
OR NECK ON ONE SIDE OF THE BODY.
MULTIFOCAL ->MULTIPLE BODY PARTS SEIZE IN SEQUENTIAL PATTERN (NONJACKSONIAN FASHION)
3. TONIC SEIZURES: 2TYPES:
FOCAL-> SUSTAINED POSTURING OF A LIMB, ASSYMETRIC POSTURING OF TRUNK NECK OR BOTH
GENERALISED-> TONIC EXTENSION OF BOTH UPPER AND LOWER LIMBS SUCH AS DECEBRATE POSTURE.
OR IT COULD BE FLEXION OF UL AND EXTENSION OF LL AS IN DECORTICATE POSTURE
4. MYOCLONIC SEIZURES: BOTH PRETERM AND FULLTERMS. SINGLE OR MULTIPLE SYNCHRONOUS JERKS.
FOCAL, MULTIFOCAL AND GENRALISED ARE THE SUBTYPES.
DIAGNOSIS?
1. HISTORY: POSITIVE FAMILY HISTORY, MATERNAL DRUG HISTORY (NARCOTIC
WITHDRAWAL) AND DELIVERY (ANALGESIA GIVEN, ANY TRAUMA, FETAL INTRAPARTUM
STATUS, INFECTIONS, ANY RESUSCITATIVE MEASURES TAKEN)
2. PHYSICAL EXAMINATION: IMPORTANT IS HEAD CIRCUMFERENCE, DYSMORPHIC
FEATURES, GESTATIONAL AGE, CNS EXAMINATION AND SEIZURE PATTERN.
3. LABORATORY STUDIES: CBC, SERUM CHEMISTRIES, AND CSF FLUID D/R , CULTURE AND
PCR, METABOLIC DISORDERS.
4. IMAGING:
U/S (ANY HAEMORRHAGE)
CT (INFARCTION, HAEMORRHAGE, CALCIFICATION, MALFORMATIONS)
MRI (LISSENCEPHALY, PACHYGYRIA, POLYMICROGYRIA, HIE, IVH)
EEG (CONVENTIONAL FULL ARRAY CONTINUOUS VIDEO EEG IS GOLD STANDARD)
MANAGEMENT:
• URGENT TREATMENT OF REPEATED SEIZURES IS CRUCIAL TO REDUCE THE CHANCES OF BRAIN INJURY.
AFTER CHECKING FOR AIRWAY BREATHING AND CIRCULATION, THE METHOD OF TREATMENT DEPENDS ON THE
CAUSE.
1. HYPOGLYCEMIA – 10% DW 2 TO 4ML PER KG IV, FOLLOWED BY 6 TO 8MG/KG/MIN INFUSION
2. HYPOCALCEMIA – SLOW CALCIUM GLUCONATE INFUSION.
3. HYPOMAGNESEMIA – MAGNESIUM SULPHATE
4. ANTI CONVULSANTS: THESE ARE GIVEN WHEN NO UNDERLYING METABOLIC REASON IS FOUND. LOADING DOSES
OF PHENYTOIN AND PHENOBARBITAL HELP IN REDUCING 85% OF SEIZURES
>PHENOBARBITAL – USUALLY INITIAL DRUG OF CHOICE.
>PHENYTOIN – FOSPHENYTOIN IS A PREFERRED FORM, USED AS A SECOND LINE.
IF SEIZURES STILL PERSIST?
BENZO SUCH AS DIAZEPAM IS USED: CONTINUOUS INFUSION AT 0.3MG/KG/HR
IT HAS RAPID BRAIN CLEARANCE, RISK OF CIRCULATORY FAILURE IF USED WITH PHENOBARBITAL, NARROW
THERAPEUTIC INDEX/ TOXICITY WINDOW AND GREATER DEPRESSANT EFFECT.
LORAZEPAM- GIVEN IV 4 TO 6 TIMES IN 24HRS. CAUSES LESS SEDATION AND RESPIRATORY DEPRESSION. ALSO HAS
LESS RAPID BRAIN CLEARANCE. IT IS QUITE EFFECTIVE AND SAFE.
MANAGEMENT (CONT..)
5. IF SEIZURES PERSIST?
RULE OUT DISORDERS SUCH AS :
PYRIDOXINE DEPENDENT SEIZURES- VITAMIN B6 IS GIVEN TO SEE IF SEIZURES STOP QUICKLY. 50-100MG IV WITH EEG MONITORING
IS RECOMMENDED.
FOLINIC ACID RESPONSIVE SEIZURES (RARE) – GIVE FOLINIC ACID 2.5MG TWICE DAILY
DEVIVO SYNDROME – KETOGENIC DIET ADVISED (GLUCOSE TRANSPORTER DEFICIENCY)
6. IF SEIZURES STILL PERSIST, FOLLOWING DRUGS COULD BE ADDED:
> HIGH DOSE PHENOBARBITAL
> MIDAZOLAM
>PENTOBARBITAL
>THIOPENTAL
>CLONAZEPAM
>VALPROIC ACID
>LIDOCAINE
>TOPIMARATE
>LAMOTRIGINE
>CARBAMAZEPINE
>VIGABATRIN
DURATION OF ANTICONVULSANT THERAPY? THE OPTIMAL DURATION OF ANTICONVULSANT THERAPY IS NOT ESTABLISHED.
HOWEVER PHENOBARBITAL SHOULD BE PROLONGED IF SEIZURES STOP IN 2 WEEKS.
COMPLICATIONS AND PROGNOSIS:
• IF SEIZURES ARE CORRECTED AND CONTROLLED EARLY (IN TRANSIENT OR
METABOLIC DISORDERS); OUTCOME IS FAVOURABLE.
• IN CNS INFECTIONS, HIE, BRAIN MALFORMATIONS; OUTCOMES NOT FAVOURABLE.
• COMPLICATIONS COULD INCLUDE:
1. CEREBRAL PALSY
2. EPILEPSY
3. MENTAL RETARDATION
4. LEARNING DISORDER
5. NEURODEVELOPMENTAL IMPAIRMENT
6. VISION HEARING IMPAIRMENT
7. DEATH
SUMMARY