neonatal seizures
Post on 07-May-2015
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Protocols of Neonatalseizure
Neonatal seizures (NS) are the most frequent and distinctive clinical manifestation of neurological dysfunction in the newborn infant.
Definition:-
A seizure is defined clinically as a paroxysmal alteration in neurologic function, i.e. motor, behavior and/or autonomic function.
1. Epileptic seizures: phenomena associated with
corresponding EEG seizure activity e.g. clonic seizures
2. Non-epileptic seizures: clinical seizures without corresponding EEG correlate e.g. subtle and generalized tonic seizures
3. EEG seizures: abnormal EEG activity with no clinical correlation.
Classification:-
Subtle seizures: They are the commonest type
1. Ocular - Tonic horizontal deviation of eyes or sustained eye opening with ocular fixation or cycled fluttering
2. Oral–facial–lingual movements - Chewing, tongue- thrusting, lip-smacking, etc.
3. Limb movements - Cycling, paddling, boxing-jabs, etc
4. Autonomic phenomena - Tachycardia or bradycardia
5. Apnea may be a rare manifestation of seizures. Apnea due to seizure activity has an accelerated or a normal heart rate when evaluated 20 seconds after onset.
Clonic seizures: They are rhythmic movements of muscle
groups. They have both fast and slow components, occur with a frequency of 1-3 jerks per second
Tonic seizures: refers to a sustained flexion or extension
of axial orappendicular muscle group
Myoclonic seizures:
manifest as single or multiple lightning fast jerks of theupper or lower limbs and are usually distinguished from clonic movements because of more rapid speed of myoclonic jerks, absence of slow return and predilection for flexor muscle groups
Myoclonic seizures carry the worst prognosis in terms of neuro-developmental outcome and seizure recurrence. Focal clonic seizures have the best prognosis.
Aiims protocol:- identify and characterize seizure
Nurse the baby in TNZ( room temp 26’-28’ C)
Maintain airway ,breathing, circulation , start O2
Check blood glucose (<40mg) and give glucose @ 8mg/kg (2ml/kg of D10 %)
Give 2ml/kg of 10% of ca gluconate over 10 min
0.25ml/kg of 50% mgso4 i/m
Phenobarbitone 20mg/kg over 20 min
Give phenobaritone again @ 10mg/kg
Give maintenance dose 3-5 mg/day
Phenytoin 20mg/kg over 20 min
Repeat phenytoin 10mg/kg
Benzodiazepines used
Lorazepam: 0.05 mg/kg IV bolus over 2-5 minutes or
Midazolam: 0.15 mg/kg IV bolus followed by infusion of 0.1 to 0.4 mg/kg/hour
In refractory seizurez second line drugs can be used
Lidocaine 4mg/kg iv followed by 2mg/kg/hr or
Sodium valproate 20-25mg/kg/day followed by 5-10mg/kg/day
Other drugs like vigabatrin. Topiramate, paraldehyde
Therapeutic trial of pyridoxine
1 ml of neurobion on both gluteus i/m
IAP Protocol:-
Maintain ABC and temperature
Check blood glucose
Correct glucose and calcium
Administer IV, phenobarbitone 20mg/kg
Repeat in 5 mg/kg boluses till a maximum of 40 mg/kg, every 15 minutes if seizure continues
IV phenytoin 15-20 mg/kg diluted in equal volume of normal saline at a maximum rate of 1mg/kg/min over 35-40 minutes
IV lorazepam (0.05-0.1 mg/kg ) or dizepam ( 0.25 mg/kg bolusOr 0.5 mg/kg rectal )
IV midazolam as a continuous infusion (as initial IV bolus of 0.15 mg/kg, followed by continuous infusion (1ug/kg/min )
increasing by 0.5-1 ug/kg/min every 2 minutes until a favorable response or a maximum of 18ug/kg/min
100 mg pyridoxine IV or oral ( if IV not available ) should be given
Nelson Protocol:-
Maintain ABC and temperature
Check blood glucose
Correct glucose and calcium
Administer IV, phenobarbitone 20mg/kg
Repeat in 5 -10mg/kg boluses till a maximum of 40 mg/kg,
IV phenytoin 15-20 mg/kg diluted in equal volume of normal saline at a maximum rate of 1mg/kg/min over 35-40 minutes
IV lorazepam 0.05 mg/kg every 4-8 hourly
IV midazolam as a continuous infusion (as initial IV bolus of 0.05-0.1mg/kg, followed by continuous infusion
(0.5-1ug/kg/min ) increasing by 2 ug/kg/min every 5 minutes to achieve seizure control
Primidone, lidocaine, carbamazepine, valproate, lamotrigine, topiramate, and levetiracetam have been used.
Weaning of anticonvulsant therapy
Newborn on anticonvulsant therapy
Wean all antiepileptic drugs except phenobarbitone once seizure controlled
Perform neurological examination prior to discharge
normal Abnormal
Stop phenobarbitone
prior to discharge
Continue phenobarbitone
for 1 month
Repeat neurological
examination at 1 month of age
Abnormal examination
Normal examination
Taper drugs over 2 week
Evaluate EEG
Normal EEGTaper drug
over 2 weeks
Abnormal EEGContinue drugReassess at 3
months
Dr.Priyank Patel
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