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Management of Convulsive Seizures
MANAGEMENT OF (;ONVULSIVE SEIZURES MARTIN
J.
HARRIS, M.R.C.S., L.R.C.P. (ENGLAND)
':;onvulsive seizures are symptoms of an underlying disease process involving the central nervous system, whether it be an anatomic derangement or a disorder of physiologic or biochemical processes. They constitute a pediatric emergency and must be dealt with at once in order to prevent damage to the brain. The first convulsion which a mother sees her child have is a very frightening experience. She has probably never seen one before and is helpless. The physician should see the child as soon as he is called. In the meantime a mouth gag should be used in an effort to provide an airway. Two butter knives can be taped together and wrapped with gauze and placed between the child's teeth to prevent him from biting his tongue. His tongue is then pulled and held forward. If the child is febrile, he should be put into a tub of water which is just cool to the touch. It can then be made slowly colder by adding cold water. An alternative to this, but not as good, is to rub the child with a mixture of alcohol and water (1:2). Continual ice packs to the back, axillae and abdomen are effective. When the child is seen by the physician, the seizures are controlled, and therapy is started to correct the underlying cause when possible. NEONATAL CONVULSIONS
These are due to inborn brain defects, both trauma or anoxia, infection, and metabolic defects. Since newborn infants are frequently dismissed from the hospital with their mothers within a day or two after birth, convulsions from these causes may not be detected until the child is home. The first sign of trouble may be cyanotic spells which eventually develop into frank convulsions. A history of the pregnancy and delivery is important. One needs to inquire about such things as resuscitative measures at birth. Physical examination should include investigation of such things as the condition of the fontanel, stiffness of the neck, pupil size and equality, muscle tone and the reflexes. 193
194
MANAGEMENT OF CONVULSIVE SEIZURES
Frequently convulsions in the newborn or older infant go unrecognized by the uninitiated. The infant may lie with his head to one side, anns and legs extended, with short, almost imperceptible jerks and lateral nystagmus. Feedings are not taken. Generalized, more extensive jerking or localized seizures are easily recognized. These infants should be given anticonvulsant therapy and hospitalized for study. The infant is particularly susceptible to sepsis from birth until two to three weeks of age. A poor feeding history, vomiting, excessive sleepiness or "jitteriness" should make one suspicious of generalized sepsis, including central nervous system involvement. These infants are often afebrile and may have nonnal blood cell counts. They should be hospitalized. If seizures occur in the newborn after he has seemed nonnal for a few days, he may have tetany or some other metabolic defect and should be hospitalized for study. Older infants, those up to the age of one year, who have seizures without evidence of infection (pyogenic, viral, tuberculous) or lead encephalitis should be suspected of having had intrauterine trauma to the central nervous system or developmental defects. The outlook for a nonnal developmental pattern is poor when seizures are due to developmental defect or trauma, subdural hematoma having been ruled out. In the newborn intramuscular injections of phenobarbital sodium, ¥4 grain, repeated once in 30 minutes and then every 4 to 6 hours as necessary, plus Dilantin, % grain orally daily, usually control the seizures. After a day or two the phenobarbital is given orally. Parents of these infants require much time and patience. The physician must explain the mechanism of the seizures and give a guarded prognosis. I know of no condition in pediatrics in which more time must be spent with parents, repeating the same thing over and over again. It is frequently a good plan to suggest having another professional opinion. Phenylpyruvic oligophrenia should be considered and investigated in any infant who is blond, whose sibling has the disease or is retarded, or in one who has eczema and associated abnormal behavior or convulsions. Testing should be done after three weeks of age. Ferric chloride solution, 5 or 10 per cent, is dropped on a recently wet diaper. A green color indicates phenylketonuria. With nonnal urine the color remains yellow. The test tube test is performed by adding 3 drops of the ferric chloride solution to 1 cc. of urine. A green color is positive. If the ferric chloride test is positive, it should be con finned by the phenylhydrazine test. Treatment is directed toward reducing the phenylalanine content of the diet. Meade Johnson's Lofenalac and Merck's Ketonil are food preparations which meet this requirement. CEREBRAL PALSY
Seizures may occur in infancy before spasticity is detected. The management of these convulsions is the same as for all other varieties.
MARTIN
J.
HARRIS
195
FEBRILE CONVULSIONS
Febrile convulsions are rare before the age of six to eight months and occur up to four years. The child has been previously healthy and has a fever of at least 102° F. rectally, but often higher. The seizure lasts less than 3D- minutes. He is usually normal neurologically when the seizure is over. Febrile convulsions are due to any infectious process or occasionally hyperthermia, such as that which may be encountered in a poorly ventilated croup tent in which the high environmental temperature plus the infectious process causes high fever. Injections of vaccines may also cause convulsions. These may be secondary to the fever, but may rarely be caused by encephalomyelitis. It is not so much the etiologic agent which causes the seizures, but rather the sudden rise in body temperature in a susceptible child. Convulsive seizures associated with meningitis are due to this disease and not to the fever. If the child is still having convulsions when he is seen by the physician, they must be dealt with at once. Any of the following procedures may be followed in an effort to stop the convulsions. Intramuscular paraldehyde, 1.5 cc. per 10 pounds of body weight. Give deeply into the muscle and not more than 3 or 4 cc. in one place. Repeat with half the dose in a half-hour if necessary. Phenobarbital sodium, 30 mg. per 10 pounds of body weight, intramuscularly. Repeat with half the dose in a half-hour if necessary. It must be remembered that barbiturates are respiratory depressants. Capsules Nembutal or Seconal, %, grain for 6 months to 1112 years, and 1Y2 grains from 1Y2 to 4 years, emptied in 2 drams of water and injected into the rectum with an enema syringe, holding the buttocks together for 10 minutes. If the seizure is still uncontrolled, consider (a) open drop ether, (b) paraldehyde, 20 cc. dissolved in normal saline solution,and given intravenously through a drip until control is attained. Sodium Amy tal is mentioned only to be condemned because of the small margin of safety between control of convulsions and serious respiratory depression. It is most effective in experienced hands. Other temperature control measures are instituted as soon as the initial sedatives are given . .Medications to lower the temperature are given as follows: Thorazine intramuscularly or by suppository; 5 mg. intramuscularly for infants to 10 mg. for 4-year-olds. Suppositories, 12.5 mg. for infants to 25 mg. for 4-year-oIds. Aspirin by suppository (not as good as Thorazine). The dosage for infants to 4 years is 2 to 5 grains, but do not repeat for 6 hours. Pyralgin (Savage Pharmaceutical Company), intramuscularly, 0.5 cc. for infants to 2 cc. for 4-year-oIds (do not give with Thorazine, since it may cause hypothermia); or drops, 0.5 cc. for infants to 1 cc. for older children; or syrup, Y2 to 1 teaspoonful for infants to 6 years of age. Pyralgin and Thorazine have been found to be the best of the antipyretics. The former is being used with increased frequency at the Children's Hospital in Louisville for pyrexia and thus far has been
196
MANAGEMENT OF CONVULSIVE SEIZURES
the most effective of any drug. No unfavorable effects are encountered when it is given in recommended doses as needed. The child will have more convulsions unless the body temperature is lowered and kept down. Sometimes it is necessary to hospitalize him in order to carry out adequate temperature control measures. When the febrile seizure is under control, the child is examined to determine the cause. If physical signs and a urinalysis are of no help, an examination of the spinal fluid is indicated. The appearance of the fluid should be noted. Then a cell count, examination of sediment and a culture should be done. Bacterial meningitis and viral or lead encephalitis frequently do not cause neck stiffness for several days in infants. A seizure due to meningitis is often preceded by a period of sleepiness with fever, which is unusual for the child. Once a child has a febrile convulsion he is vulnerable to them each time he has fever. The parents should be informed of this. A prescription of Nembutal suppositories, Vz grain, no. 10, is sent home with instructions that one should be inserted into the rectum when fever over 101 0 F. rectally develops, and every 8 to 12 hours thereafter if necessary according to age. Pyralgin should be given for one dose only at the same time, and the child should be seen by the physician as soon as it is practical to do so. If the child gets three or more pyrexial attacks with associated seizures, it is well to put him on continuous phenobarbital, ~ to Vz grain twice or 3 times daily. If this does not control him, Dilantin, % grain daily, should be added. It is interesting to note that the incidence of idiopathic epilepsy is uncommon in children having uncomplicated febrile seizures. When there is a history of epilepsy in the family, the incidence is higher. Children under three years of age sometimes have residual paresis following convulsions. These are probably due to small vascular accidents and usually, but not always, clear up without residuals. Unless the etiology of the convulsive seizure in the infant is certain, electroencephalography is indicated and may be helpful. It is especially so in hypsarrhythmia (massive spasm), which occurs most frequently between the third and twelfth months of life, but has been seen from one day to three years of age. It is characterized by sudden jerking or body flexion. The arms are flung out and the entire body shakes. The electroencephalogram is usually diagnostic. Severe mental and physical retardation results unless the seizures are controlled. Steroid therapy seems to be helpful in the treatment of this type of seizure.1 THE EPILEPSIES
The chief goals in the treatment of seizures are (I) control of the convulsions, while at the same time not causing such side effects as to prevent the child from leading a reasonably normal life, and (2) lack of toxicity in effective dosage. Usually two or more medications are combined, each in a dose below that causing undesired reactions because of the frequent toxicity of the most useful drugs alone in effective dosage.
MARTIN
J.
HARRIS
197
Grand Mal
Usually a parent calls the physician, telling him that his child has had a seizure, either at school or while playing. It lasted for a few minutes, and after a period of sleepiness he seemed normal. Sometimes, upon awakening in the morning, the tongue has been bitten and is bleeding. An appointment is made by the physician for a general unhurried examination. A careful history is taken from someone, if possible, who was a witness to the seizure. One inquires into the family history of convulsions in a casual manner, preferably in the presence of only one parent at a time. Nothing is gained by having a parent maintain a feeling of guilt about his being the carrier of disease. After a careful physical examination routine laboratory procedures such as blood cell count and urinalysis are done. If it is decided that the electroencephalogram is indicated, this should be arranged about two weeks after the seizure. It is necessary to explain to the parents that this is advisable in order to get a true tracing. It must be realized that this period is going to be one of much apprehension to the parents, and they should be given as detailed an explanation of the findings as possible. They should be told of the limitations of the electroencephalogram. If the child has had only one short grand mal seizure, he may never have another. It is perhaps best to wait until he has a second seizure before beginning therapy. "Science and Seizures" by William G. Lennox is recommended reading for parents. If the child is seen during a seizure or during status epilepticus, he is treated as outlined under Febrile Convulsions. When grand mal has been definitely diagnosed and treatment decided upon, the problem is discussed with the family in the child's presence. There must be some restriction of activity. The child should not ride a bicycle or go swimming unattended until he has been seizurefree for at least one year. Tablets of phenobarbital, ~ to Y2 grain 2 or 3 times daily, are prescribed. It is well to start with a small dose for 4 to 5 days and then increase to Y2 grain or even a higher dose if it is not too sedative. Occasionally excessive irritability results from phenobarbital. If this occurs, Mebaral may be substituted. In addition to the barbiturate, Dilantin is prescribed. We begin with % grain daily and increase as needed to tolerance. Ataxia, nystagmus, diplopia and lassitude indicate overdosage. The drug should be stopped for three days and then resumed with a smaller dose. The parents should be told to watch for the development of a rash one to three weeks after Dilantin therapy has been started. At first the rash is scarlatiniform and then becomes morbilliform. Exfoliative dermatitis may result if medication is not discontinued at once. Fever to 103° F. and glandular enlargement may accompany the rash and may persist for several days. The patient who has such reactions cannot take Dilantin again. With mild rashes and no fever Dilantin may be tolerated again after the drug has been discontinued for a few days. Other adverse side effects are hypertrophy of the gums and hirsutism.
198
MANAGEMENT OF CONVULSIVE SEIZURES
There is no way to overcome these effects except by discontinuation of the drug. This should not be done, however. Mesantoin may be substituted for Dilantin if seizures continue when both phenobarbital and Dilantin are administered to tolerance. Mesantoin, however, is more toxic than Dilantin, causing rashes and depression of the bone marrow. Mysoline may also be tried if the other medications fail, adding it to the phenobarbital and Dilantin in increasing dosage to tolerance. It is important not to discontinue all medications at one time if they are not entirely effectual. The patient may then go into status epilepticus. Start a new drug before discontinuing the old ones. If control of the seizures is stilI not satisfactory, the patient should be referred to a neurologist. Patients are kept on medication for five years. Medications are gradually discontinued over a period of one to two years if the seizures have been under control for this period. Medication should be continued indefinitely if there is an occasional seizure. Petit Mal
Petit mal is characterized by sudden, brief loss of postural tone. Eye staring and unsteadiness, with only momentary loss of consciousness, may occur many times a day (often 200). It occurs in children and usually disappears by the age of twenty. Attacks may be produced in the office by deep respirations. Akinetic Attacks
Akinetic attacks are manifest by the patient's dropping to the floor, or he may only "slump" a little. There may be sudden head nodding. In myoclonic seizures the patient stops, stares and jerks his head, eyes and hands about three times a second. Such seizures as these are best referred to a neurologist for management. If the attacks of petit mal are seen by the physician or a good witness, the child is completely examined, and a blood cell count, urinalysis and electroencephalogram are obtained. Phenobarbital is begun in small doses and increased to tolerance. Tridione therapy is instituted. At first one capsule is given in the morning for four days. The dosage is gradually increased by one capsule until the attacks are controlled. As many as nine capsules daily may be given. If the seizures are not controlled with this dosage, a Paradione capsule can be substituted every fourth or fifth day for a Tridione capsule. If the Paradione is not effectual, it is discontinued, and Milontin is substituted. As with all drugs for the control of epilepsy, the patient must be carefully watched for toxic effects when he is receiving Tridione or Paradione. Tridione causes rash and sensitivity to light. Leukopenia sometimes results from this drug, even after many months of therapy. Monthly blood cell counts should be performed and the drug discontinued if leukopenia develops. Nephrosis has also been reported with
MARTIN
J.
HARRIS
199
Tridione. Urinalysis should be a part of the follow-up examinations. Paradione causes the same side effects as Tridione, but to a less degree. When there are grand mal and petit mal attacks combined, the more severe type is treated first. Phenobarbital is started and pushed to full dosage. Tridione tends to aggravate grand mal attacks. Consequently, Milontin, 10 to 20 mg. per pound per day, is prescribed to control the petit mal. If the grand mal attacks get worse, Mysoline, 6 to 12 mg. per pound per day, is added, since Dilantin tends to make the petit mal worse. The toxic effects of Mysoline are drowsiness, ataxia and rashes. Medications for petit mal should be continued until the child is seizure-free for six months. Medications are gradually reduced, keeping the full dosage of phenobarbital till all other medications are stopped. The dosage of phenobarbital is reduced to discontinuance in a year. Although a large percentage of youngsters who have grand mal and petit mal attacks are well controlled, there are a great many in whom the control of these seizures constitutes one of the greatest challenges in neurology. This is even more true in the other varieties of seizures. The many new drugs being put on the market are an indication of this unfortunate state of affairs. SUMMARY
Convulsive seizures are due to central nervous system disorder, anatomic, physiologic or biochemical. Treatment is directed toward the cause when possible. However, seizures are frequently associated with fever or are a form of idiopathic epilepsy. Their management has been discussed. REFERENCE 1. Stamps and others: Treatment of hypsarrhythmia with A.C.T.H., '.A.M.A., 171: 1959. 804 Francis Building Louisville 2, Ky.
J.
HARRIS, M.R.C.S., L.R.C.P. (ENGLAND)
':;onvulsive seizures are symptoms of an underlying disease process involving the central nervous system, whether it be an anatomic derangement or a disorder of physiologic or biochemical processes. They constitute a pediatric emergency and must be dealt with at once in order to prevent damage to the brain. The first convulsion which a mother sees her child have is a very frightening experience. She has probably never seen one before and is helpless. The physician should see the child as soon as he is called. In the meantime a mouth gag should be used in an effort to provide an airway. Two butter knives can be taped together and wrapped with gauze and placed between the child's teeth to prevent him from biting his tongue. His tongue is then pulled and held forward. If the child is febrile, he should be put into a tub of water which is just cool to the touch. It can then be made slowly colder by adding cold water. An alternative to this, but not as good, is to rub the child with a mixture of alcohol and water (1:2). Continual ice packs to the back, axillae and abdomen are effective. When the child is seen by the physician, the seizures are controlled, and therapy is started to correct the underlying cause when possible. NEONATAL CONVULSIONS
These are due to inborn brain defects, both trauma or anoxia, infection, and metabolic defects. Since newborn infants are frequently dismissed from the hospital with their mothers within a day or two after birth, convulsions from these causes may not be detected until the child is home. The first sign of trouble may be cyanotic spells which eventually develop into frank convulsions. A history of the pregnancy and delivery is important. One needs to inquire about such things as resuscitative measures at birth. Physical examination should include investigation of such things as the condition of the fontanel, stiffness of the neck, pupil size and equality, muscle tone and the reflexes. 193
194
MANAGEMENT OF CONVULSIVE SEIZURES
Frequently convulsions in the newborn or older infant go unrecognized by the uninitiated. The infant may lie with his head to one side, anns and legs extended, with short, almost imperceptible jerks and lateral nystagmus. Feedings are not taken. Generalized, more extensive jerking or localized seizures are easily recognized. These infants should be given anticonvulsant therapy and hospitalized for study. The infant is particularly susceptible to sepsis from birth until two to three weeks of age. A poor feeding history, vomiting, excessive sleepiness or "jitteriness" should make one suspicious of generalized sepsis, including central nervous system involvement. These infants are often afebrile and may have nonnal blood cell counts. They should be hospitalized. If seizures occur in the newborn after he has seemed nonnal for a few days, he may have tetany or some other metabolic defect and should be hospitalized for study. Older infants, those up to the age of one year, who have seizures without evidence of infection (pyogenic, viral, tuberculous) or lead encephalitis should be suspected of having had intrauterine trauma to the central nervous system or developmental defects. The outlook for a nonnal developmental pattern is poor when seizures are due to developmental defect or trauma, subdural hematoma having been ruled out. In the newborn intramuscular injections of phenobarbital sodium, ¥4 grain, repeated once in 30 minutes and then every 4 to 6 hours as necessary, plus Dilantin, % grain orally daily, usually control the seizures. After a day or two the phenobarbital is given orally. Parents of these infants require much time and patience. The physician must explain the mechanism of the seizures and give a guarded prognosis. I know of no condition in pediatrics in which more time must be spent with parents, repeating the same thing over and over again. It is frequently a good plan to suggest having another professional opinion. Phenylpyruvic oligophrenia should be considered and investigated in any infant who is blond, whose sibling has the disease or is retarded, or in one who has eczema and associated abnormal behavior or convulsions. Testing should be done after three weeks of age. Ferric chloride solution, 5 or 10 per cent, is dropped on a recently wet diaper. A green color indicates phenylketonuria. With nonnal urine the color remains yellow. The test tube test is performed by adding 3 drops of the ferric chloride solution to 1 cc. of urine. A green color is positive. If the ferric chloride test is positive, it should be con finned by the phenylhydrazine test. Treatment is directed toward reducing the phenylalanine content of the diet. Meade Johnson's Lofenalac and Merck's Ketonil are food preparations which meet this requirement. CEREBRAL PALSY
Seizures may occur in infancy before spasticity is detected. The management of these convulsions is the same as for all other varieties.
MARTIN
J.
HARRIS
195
FEBRILE CONVULSIONS
Febrile convulsions are rare before the age of six to eight months and occur up to four years. The child has been previously healthy and has a fever of at least 102° F. rectally, but often higher. The seizure lasts less than 3D- minutes. He is usually normal neurologically when the seizure is over. Febrile convulsions are due to any infectious process or occasionally hyperthermia, such as that which may be encountered in a poorly ventilated croup tent in which the high environmental temperature plus the infectious process causes high fever. Injections of vaccines may also cause convulsions. These may be secondary to the fever, but may rarely be caused by encephalomyelitis. It is not so much the etiologic agent which causes the seizures, but rather the sudden rise in body temperature in a susceptible child. Convulsive seizures associated with meningitis are due to this disease and not to the fever. If the child is still having convulsions when he is seen by the physician, they must be dealt with at once. Any of the following procedures may be followed in an effort to stop the convulsions. Intramuscular paraldehyde, 1.5 cc. per 10 pounds of body weight. Give deeply into the muscle and not more than 3 or 4 cc. in one place. Repeat with half the dose in a half-hour if necessary. Phenobarbital sodium, 30 mg. per 10 pounds of body weight, intramuscularly. Repeat with half the dose in a half-hour if necessary. It must be remembered that barbiturates are respiratory depressants. Capsules Nembutal or Seconal, %, grain for 6 months to 1112 years, and 1Y2 grains from 1Y2 to 4 years, emptied in 2 drams of water and injected into the rectum with an enema syringe, holding the buttocks together for 10 minutes. If the seizure is still uncontrolled, consider (a) open drop ether, (b) paraldehyde, 20 cc. dissolved in normal saline solution,and given intravenously through a drip until control is attained. Sodium Amy tal is mentioned only to be condemned because of the small margin of safety between control of convulsions and serious respiratory depression. It is most effective in experienced hands. Other temperature control measures are instituted as soon as the initial sedatives are given . .Medications to lower the temperature are given as follows: Thorazine intramuscularly or by suppository; 5 mg. intramuscularly for infants to 10 mg. for 4-year-olds. Suppositories, 12.5 mg. for infants to 25 mg. for 4-year-oIds. Aspirin by suppository (not as good as Thorazine). The dosage for infants to 4 years is 2 to 5 grains, but do not repeat for 6 hours. Pyralgin (Savage Pharmaceutical Company), intramuscularly, 0.5 cc. for infants to 2 cc. for 4-year-oIds (do not give with Thorazine, since it may cause hypothermia); or drops, 0.5 cc. for infants to 1 cc. for older children; or syrup, Y2 to 1 teaspoonful for infants to 6 years of age. Pyralgin and Thorazine have been found to be the best of the antipyretics. The former is being used with increased frequency at the Children's Hospital in Louisville for pyrexia and thus far has been
196
MANAGEMENT OF CONVULSIVE SEIZURES
the most effective of any drug. No unfavorable effects are encountered when it is given in recommended doses as needed. The child will have more convulsions unless the body temperature is lowered and kept down. Sometimes it is necessary to hospitalize him in order to carry out adequate temperature control measures. When the febrile seizure is under control, the child is examined to determine the cause. If physical signs and a urinalysis are of no help, an examination of the spinal fluid is indicated. The appearance of the fluid should be noted. Then a cell count, examination of sediment and a culture should be done. Bacterial meningitis and viral or lead encephalitis frequently do not cause neck stiffness for several days in infants. A seizure due to meningitis is often preceded by a period of sleepiness with fever, which is unusual for the child. Once a child has a febrile convulsion he is vulnerable to them each time he has fever. The parents should be informed of this. A prescription of Nembutal suppositories, Vz grain, no. 10, is sent home with instructions that one should be inserted into the rectum when fever over 101 0 F. rectally develops, and every 8 to 12 hours thereafter if necessary according to age. Pyralgin should be given for one dose only at the same time, and the child should be seen by the physician as soon as it is practical to do so. If the child gets three or more pyrexial attacks with associated seizures, it is well to put him on continuous phenobarbital, ~ to Vz grain twice or 3 times daily. If this does not control him, Dilantin, % grain daily, should be added. It is interesting to note that the incidence of idiopathic epilepsy is uncommon in children having uncomplicated febrile seizures. When there is a history of epilepsy in the family, the incidence is higher. Children under three years of age sometimes have residual paresis following convulsions. These are probably due to small vascular accidents and usually, but not always, clear up without residuals. Unless the etiology of the convulsive seizure in the infant is certain, electroencephalography is indicated and may be helpful. It is especially so in hypsarrhythmia (massive spasm), which occurs most frequently between the third and twelfth months of life, but has been seen from one day to three years of age. It is characterized by sudden jerking or body flexion. The arms are flung out and the entire body shakes. The electroencephalogram is usually diagnostic. Severe mental and physical retardation results unless the seizures are controlled. Steroid therapy seems to be helpful in the treatment of this type of seizure.1 THE EPILEPSIES
The chief goals in the treatment of seizures are (I) control of the convulsions, while at the same time not causing such side effects as to prevent the child from leading a reasonably normal life, and (2) lack of toxicity in effective dosage. Usually two or more medications are combined, each in a dose below that causing undesired reactions because of the frequent toxicity of the most useful drugs alone in effective dosage.
MARTIN
J.
HARRIS
197
Grand Mal
Usually a parent calls the physician, telling him that his child has had a seizure, either at school or while playing. It lasted for a few minutes, and after a period of sleepiness he seemed normal. Sometimes, upon awakening in the morning, the tongue has been bitten and is bleeding. An appointment is made by the physician for a general unhurried examination. A careful history is taken from someone, if possible, who was a witness to the seizure. One inquires into the family history of convulsions in a casual manner, preferably in the presence of only one parent at a time. Nothing is gained by having a parent maintain a feeling of guilt about his being the carrier of disease. After a careful physical examination routine laboratory procedures such as blood cell count and urinalysis are done. If it is decided that the electroencephalogram is indicated, this should be arranged about two weeks after the seizure. It is necessary to explain to the parents that this is advisable in order to get a true tracing. It must be realized that this period is going to be one of much apprehension to the parents, and they should be given as detailed an explanation of the findings as possible. They should be told of the limitations of the electroencephalogram. If the child has had only one short grand mal seizure, he may never have another. It is perhaps best to wait until he has a second seizure before beginning therapy. "Science and Seizures" by William G. Lennox is recommended reading for parents. If the child is seen during a seizure or during status epilepticus, he is treated as outlined under Febrile Convulsions. When grand mal has been definitely diagnosed and treatment decided upon, the problem is discussed with the family in the child's presence. There must be some restriction of activity. The child should not ride a bicycle or go swimming unattended until he has been seizurefree for at least one year. Tablets of phenobarbital, ~ to Y2 grain 2 or 3 times daily, are prescribed. It is well to start with a small dose for 4 to 5 days and then increase to Y2 grain or even a higher dose if it is not too sedative. Occasionally excessive irritability results from phenobarbital. If this occurs, Mebaral may be substituted. In addition to the barbiturate, Dilantin is prescribed. We begin with % grain daily and increase as needed to tolerance. Ataxia, nystagmus, diplopia and lassitude indicate overdosage. The drug should be stopped for three days and then resumed with a smaller dose. The parents should be told to watch for the development of a rash one to three weeks after Dilantin therapy has been started. At first the rash is scarlatiniform and then becomes morbilliform. Exfoliative dermatitis may result if medication is not discontinued at once. Fever to 103° F. and glandular enlargement may accompany the rash and may persist for several days. The patient who has such reactions cannot take Dilantin again. With mild rashes and no fever Dilantin may be tolerated again after the drug has been discontinued for a few days. Other adverse side effects are hypertrophy of the gums and hirsutism.
198
MANAGEMENT OF CONVULSIVE SEIZURES
There is no way to overcome these effects except by discontinuation of the drug. This should not be done, however. Mesantoin may be substituted for Dilantin if seizures continue when both phenobarbital and Dilantin are administered to tolerance. Mesantoin, however, is more toxic than Dilantin, causing rashes and depression of the bone marrow. Mysoline may also be tried if the other medications fail, adding it to the phenobarbital and Dilantin in increasing dosage to tolerance. It is important not to discontinue all medications at one time if they are not entirely effectual. The patient may then go into status epilepticus. Start a new drug before discontinuing the old ones. If control of the seizures is stilI not satisfactory, the patient should be referred to a neurologist. Patients are kept on medication for five years. Medications are gradually discontinued over a period of one to two years if the seizures have been under control for this period. Medication should be continued indefinitely if there is an occasional seizure. Petit Mal
Petit mal is characterized by sudden, brief loss of postural tone. Eye staring and unsteadiness, with only momentary loss of consciousness, may occur many times a day (often 200). It occurs in children and usually disappears by the age of twenty. Attacks may be produced in the office by deep respirations. Akinetic Attacks
Akinetic attacks are manifest by the patient's dropping to the floor, or he may only "slump" a little. There may be sudden head nodding. In myoclonic seizures the patient stops, stares and jerks his head, eyes and hands about three times a second. Such seizures as these are best referred to a neurologist for management. If the attacks of petit mal are seen by the physician or a good witness, the child is completely examined, and a blood cell count, urinalysis and electroencephalogram are obtained. Phenobarbital is begun in small doses and increased to tolerance. Tridione therapy is instituted. At first one capsule is given in the morning for four days. The dosage is gradually increased by one capsule until the attacks are controlled. As many as nine capsules daily may be given. If the seizures are not controlled with this dosage, a Paradione capsule can be substituted every fourth or fifth day for a Tridione capsule. If the Paradione is not effectual, it is discontinued, and Milontin is substituted. As with all drugs for the control of epilepsy, the patient must be carefully watched for toxic effects when he is receiving Tridione or Paradione. Tridione causes rash and sensitivity to light. Leukopenia sometimes results from this drug, even after many months of therapy. Monthly blood cell counts should be performed and the drug discontinued if leukopenia develops. Nephrosis has also been reported with
MARTIN
J.
HARRIS
199
Tridione. Urinalysis should be a part of the follow-up examinations. Paradione causes the same side effects as Tridione, but to a less degree. When there are grand mal and petit mal attacks combined, the more severe type is treated first. Phenobarbital is started and pushed to full dosage. Tridione tends to aggravate grand mal attacks. Consequently, Milontin, 10 to 20 mg. per pound per day, is prescribed to control the petit mal. If the grand mal attacks get worse, Mysoline, 6 to 12 mg. per pound per day, is added, since Dilantin tends to make the petit mal worse. The toxic effects of Mysoline are drowsiness, ataxia and rashes. Medications for petit mal should be continued until the child is seizure-free for six months. Medications are gradually reduced, keeping the full dosage of phenobarbital till all other medications are stopped. The dosage of phenobarbital is reduced to discontinuance in a year. Although a large percentage of youngsters who have grand mal and petit mal attacks are well controlled, there are a great many in whom the control of these seizures constitutes one of the greatest challenges in neurology. This is even more true in the other varieties of seizures. The many new drugs being put on the market are an indication of this unfortunate state of affairs. SUMMARY
Convulsive seizures are due to central nervous system disorder, anatomic, physiologic or biochemical. Treatment is directed toward the cause when possible. However, seizures are frequently associated with fever or are a form of idiopathic epilepsy. Their management has been discussed. REFERENCE 1. Stamps and others: Treatment of hypsarrhythmia with A.C.T.H., '.A.M.A., 171: 1959. 804 Francis Building Louisville 2, Ky.