- Email: [email protected]
Is It Just a Seizure?
Clinical Report
www.jpedhc.org
Case Studies–Acute and Chronic Care
Section Editor Sarah A. Martin, MS, RN, CPNP-PC/AC, CCRN Children’s Memorial Hospital Chicago, Illinois Terea Giannetta, MSN, RN, CPNP California State University, Fresno Fresno, California
Sharon B. Stevenson is Pediatric Nurse Practitioner and Advanced Practice Nurse, Pediatric Neurology, Arkansas Children’s Hospital, Little Rock, Ark. Reprint requests: Sharon B. Stevenson, MNSc, RN, PNP, APN, Pediatric Neurology, Arkansas Children’s Hospital, 800 Marshall Street, Slot 512-15, Little Rock, AR 72202; email: [email protected]. J Pediatr Health Care. (2006). 20, 336337. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners.
Is It Just a Seizure? Sharon B. Stevenson, MNSc, RN, PNP, APN CHIEF COMPLAINT Seizures and unusual spells during sleep. HISTORY OF PRESENT ILLNESS B.B., a 5-year-old boy, was found in bed having a first-time convulsive seizure. His dad described B.B. as “stiff and shaking all over.” B.B. had rhythmical jerking of his upper extremities but he was unsure if the legs were involved. His eyes were “rolled back,” and he had urinary incontinence. The activity lasted 5 to 10 minutes and spontaneously resolved. B.B. had post-ictal drowsiness. He was taken to the emergency room via ambulance and admitted for overnight observation. A computerized tomography (CT) scan of the head showed possible mild cerebral edema and mild ethmoidal mucosal thickening on the right greater than the left. The clinical significance of these findings is unclear. An electroencephalogram (EEG) was abnormal and consistent with benign rolandic epilepsy (BRE), an idiopathic partial epilepsy syndrome of childhood. Seizures associated with
BRE are predominantly nocturnal, begin in early childhood, and usually remit around adolescence (Peters, Camfield, & Camfield, 2001). B.B. was initially started on gabapentin (Neurontin), an antiepileptic drug (AED), and was discharged home with plans to follow-up in the outpatient neurology clinic. Other first-line AEDs prescribed to treat partial seizures, such as BRE, include carbamazepine (Tegretol) and oxcarbazepine (Trileptal). B.B. experienced excessive daytime sleepiness, a common side effect associated with gabapentin and other AEDs. Ultimately, prior to the clinic visit, he was switched to levetiracetam (Keppra), a different AED, and the daytime sleepiness improved. B.B. continued to have “some spells” unlike the first convulsive seizure. The spells would always occur during nighttime sleep. He would get out of bed and walk to another room, as if to seek a parent. Family members would notice that B.B.’s eyes were partially opened and he would sometimes speak, have chewing motions and have urinary incontinence. Following these events, he would go back
CASE STUDY QUESTIONS: 1. Could B.B. have a coexisting condition associated with the epilepsy? If so, what should be considered? 2. What further diagnostic studies should be done? 3. What are management recommendations for B.B.’s condition? 4. What follow-up should the nurse practitioner provide? Answers are on pages 361-364.
doi:10.1016/j.pedhc.2006.06.012
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to sleep. These spells occurred at least twice weekly. BIRTH AND DEVELOPMENTAL HISTORY B.B. was born at term to a 22year-old gravida 4, para 2, aborted 1 mother. Pregnancy, and labor and delivery were uncomplicated. B.B. was discharged home at day 3 of life. B.B. walked at 15 or 16 months. His speech was delayed. He was enrolled in an early intervention program where he received speech therapy. His vision and hearing were normal. He is currently in a regular classroom setting with resource assistance that consists of modified lessons. PAST MEDICAL HISTORY B.B. had multiple respiratory infections beginning as a neonate. He was later diagnosed with asthma. Poor sleep hygiene including several arousals during the night was common in his early de-
Journal of Pediatric Health Care
velopment. He has urinary incontinence associated only with the nocturnal spells. The family now questions whether this may have been some form of seizure activity. FAMILY HISTORY A maternal uncle had seizures during early childhood that resolved without treatment. There is no other pertinent family history of seizures, specifically BRE. PSYCHOSOCIAL HISTORY B.B.’s parents are divorced but they share custody. B.B. lives most of the time with mother, his older half sister, and an older full sister. REVIEW OF SYSTEMS B.B. has intermittent headaches. He describes a constant, generalized headache, along with occipital pain and pain behind the eyes. There are no reports of fever, neck pain, or nuchal rigidity. He has associated phonophobia but no pho-
tophobia and no nausea, vomiting, or diarrhea. There are no sensory or lateralizing symptoms and no reports of headache upon early awakening. The intermittent headaches do not worsen when lying down and are partially relieved with ibuprofen or acetaminophen. His asthma is well controlled. NEUROLOGICAL EXAMINATION B.B. is alert, oriented, and cooperative. He has mild dysarthria but answers age-appropriate questions correctly. On fundoscopic examination, optic discs are sharp and vessels are well-demarcated in both eyes. Cranial nerves are intact. Reflexes are symmetrical. There are no impairments noted in motor or sensory functions. REFERENCE Peters, J. M., Camfield, C. S., & Camfield, P. R. (2001). Population study of benign rolandic epilepsy: Is treatment needed? Neurology, 57, 537-539.
September/October 2006 337
www.jpedhc.org
Case Studies–Acute and Chronic Care
Section Editor Sarah A. Martin, MS, RN, CPNP-PC/AC, CCRN Children’s Memorial Hospital Chicago, Illinois Terea Giannetta, MSN, RN, CPNP California State University, Fresno Fresno, California
Sharon B. Stevenson is Pediatric Nurse Practitioner and Advanced Practice Nurse, Pediatric Neurology, Arkansas Children’s Hospital, Little Rock, Ark. Reprint requests: Sharon B. Stevenson, MNSc, RN, PNP, APN, Pediatric Neurology, Arkansas Children’s Hospital, 800 Marshall Street, Slot 512-15, Little Rock, AR 72202; email: [email protected]. J Pediatr Health Care. (2006). 20, 336337. 0891-5245/$32.00 Copyright © 2006 by the National Association of Pediatric Nurse Practitioners.
Is It Just a Seizure? Sharon B. Stevenson, MNSc, RN, PNP, APN CHIEF COMPLAINT Seizures and unusual spells during sleep. HISTORY OF PRESENT ILLNESS B.B., a 5-year-old boy, was found in bed having a first-time convulsive seizure. His dad described B.B. as “stiff and shaking all over.” B.B. had rhythmical jerking of his upper extremities but he was unsure if the legs were involved. His eyes were “rolled back,” and he had urinary incontinence. The activity lasted 5 to 10 minutes and spontaneously resolved. B.B. had post-ictal drowsiness. He was taken to the emergency room via ambulance and admitted for overnight observation. A computerized tomography (CT) scan of the head showed possible mild cerebral edema and mild ethmoidal mucosal thickening on the right greater than the left. The clinical significance of these findings is unclear. An electroencephalogram (EEG) was abnormal and consistent with benign rolandic epilepsy (BRE), an idiopathic partial epilepsy syndrome of childhood. Seizures associated with
BRE are predominantly nocturnal, begin in early childhood, and usually remit around adolescence (Peters, Camfield, & Camfield, 2001). B.B. was initially started on gabapentin (Neurontin), an antiepileptic drug (AED), and was discharged home with plans to follow-up in the outpatient neurology clinic. Other first-line AEDs prescribed to treat partial seizures, such as BRE, include carbamazepine (Tegretol) and oxcarbazepine (Trileptal). B.B. experienced excessive daytime sleepiness, a common side effect associated with gabapentin and other AEDs. Ultimately, prior to the clinic visit, he was switched to levetiracetam (Keppra), a different AED, and the daytime sleepiness improved. B.B. continued to have “some spells” unlike the first convulsive seizure. The spells would always occur during nighttime sleep. He would get out of bed and walk to another room, as if to seek a parent. Family members would notice that B.B.’s eyes were partially opened and he would sometimes speak, have chewing motions and have urinary incontinence. Following these events, he would go back
CASE STUDY QUESTIONS: 1. Could B.B. have a coexisting condition associated with the epilepsy? If so, what should be considered? 2. What further diagnostic studies should be done? 3. What are management recommendations for B.B.’s condition? 4. What follow-up should the nurse practitioner provide? Answers are on pages 361-364.
doi:10.1016/j.pedhc.2006.06.012
336
Volume 20 • Number 5
Journal of Pediatric Health Care
to sleep. These spells occurred at least twice weekly. BIRTH AND DEVELOPMENTAL HISTORY B.B. was born at term to a 22year-old gravida 4, para 2, aborted 1 mother. Pregnancy, and labor and delivery were uncomplicated. B.B. was discharged home at day 3 of life. B.B. walked at 15 or 16 months. His speech was delayed. He was enrolled in an early intervention program where he received speech therapy. His vision and hearing were normal. He is currently in a regular classroom setting with resource assistance that consists of modified lessons. PAST MEDICAL HISTORY B.B. had multiple respiratory infections beginning as a neonate. He was later diagnosed with asthma. Poor sleep hygiene including several arousals during the night was common in his early de-
Journal of Pediatric Health Care
velopment. He has urinary incontinence associated only with the nocturnal spells. The family now questions whether this may have been some form of seizure activity. FAMILY HISTORY A maternal uncle had seizures during early childhood that resolved without treatment. There is no other pertinent family history of seizures, specifically BRE. PSYCHOSOCIAL HISTORY B.B.’s parents are divorced but they share custody. B.B. lives most of the time with mother, his older half sister, and an older full sister. REVIEW OF SYSTEMS B.B. has intermittent headaches. He describes a constant, generalized headache, along with occipital pain and pain behind the eyes. There are no reports of fever, neck pain, or nuchal rigidity. He has associated phonophobia but no pho-
tophobia and no nausea, vomiting, or diarrhea. There are no sensory or lateralizing symptoms and no reports of headache upon early awakening. The intermittent headaches do not worsen when lying down and are partially relieved with ibuprofen or acetaminophen. His asthma is well controlled. NEUROLOGICAL EXAMINATION B.B. is alert, oriented, and cooperative. He has mild dysarthria but answers age-appropriate questions correctly. On fundoscopic examination, optic discs are sharp and vessels are well-demarcated in both eyes. Cranial nerves are intact. Reflexes are symmetrical. There are no impairments noted in motor or sensory functions. REFERENCE Peters, J. M., Camfield, C. S., & Camfield, P. R. (2001). Population study of benign rolandic epilepsy: Is treatment needed? Neurology, 57, 537-539.
September/October 2006 337