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