Video summary

Manejo y Abordaje de la primera crisis epiléptica Dr. E. Chávez

Main summary

Key takeaways

Educational

Main ideas & lessons (Dr. E. Chávez)

Epileptic seizure basics

  • Epileptic seizures are transient symptoms caused by abnormal electrical activity in the brain.
  • One single unprovoked seizure is not enough to diagnose epilepsy.
  • Epilepsy diagnosis (ILAE concept): epilepsy is considered when there are:
    • ≥ 2 unprovoked seizures, separated by > 24 hours, or
    • specific conditions implying a high recurrence risk, such as:
      • abnormal EEG/MRI
      • relevant family history
      • reflex/unprovoked reflex seizures
      • known epilepsy syndrome

First clinical task in the emergency setting

Determine whether the event is truly an epileptic seizure or a “seizure mimic” (i.e., a non-epileptic paroxysmal disorder/event).

  • Use careful observation, family history, and semiology.
  • Avoid assuming that every event is generalized tonic-clonic, because not all seizures present that way.

Second task: classify the seizure

  • Use caregiver history and, when available, EEG ictal/interictal patterns.
  • Seizure classification concepts:
    • Generalized vs focal vs unknown onset
    • Focal onset can be motor or non-motor
  • Semiologic descriptors emphasized:
    • tonic, tonic-clonic, myoclonic
  • Additional semiology examples:
    • Automatisms (oral/facial/manual/body; sometimes with amnesia)
      • In infants: often sucking/mouth movements
      • In older children: may “undress/walk/run” with amnesia
    • Sensory and emotional seizures (fear, chest tightness, epigastric discomfort)
    • Cognitive manifestations (aphasia, hallucinations, behavioral/cognitive changes)
    • Autonomic signs (pupillary changes, diaphoresis, GI/urinary symptoms)

Third task: determine provoked vs unprovoked

Provoked / secondary seizures (common pediatric causes)

  • Metabolic disorders
  • Central nervous system infections
  • Intoxications
  • Brain injury/trauma
  • Stroke (less frequent)
  • Acute diarrheal illness/gastroenteritis → “parainfectious seizures”
    • Noted viral etiologies: Norovirus and Rotavirus
  • Febrile seizures
    • Typically begin 6 months to 5 years (some references extend to ~6 years)
    • Treated under “triggered/provoked” seizures

Unprovoked seizures

  • No direct acute cause identified.
  • Can represent the initial presentation of epilepsy.
  • Recurrence risk mentioned:
    • After one unprovoked seizure: ~45% risk of another seizure within 5 years
    • After two unprovoked seizures: ~87% risk of recurrence

Epilepsy etiology & genetics

  • Older perspective: many cases labeled idiopathic.
  • Newer approach: genetic/chromosomal factors are increasingly identified via modern testing.
  • After classifying seizure type, determine epilepsy type:
    • focal, generalized, combined generalized and focal, or unknown origin
  • Consider other causes:
    • structural, infectious, metabolic, immune alterations
  • Core emphasis: genetics is always part of thinking, even when not always isolatable.
    • Examples: cortical dysplasias, inborn errors of metabolism, immune-related causes with genetic underpinnings.

Diagnostic approach: history, exam, and the “first crisis” workup

Medical history should cover 4 areas

  1. What the child’s condition was before the event
  2. What happened during (step-by-step if possible)
  3. What happened after (tired/confused/drowsy vs fully normal)
  4. Triggers (fever, infection, trauma, etc.)

Family/social history emphasized

  • Consanguinity (important for recessive genetics)
  • Mother’s miscarriage history and whether causes were known
  • Family history of neurological/psychiatric disease

Neurodevelopment

  • Normal development vs global developmental delay strongly affects the likelihood that events are epileptic.

Physical exam

  • “Undress and examine head-to-toe”
  • Measure head circumference and identify micro/macrocephaly
  • Look for dysmorphic features and phenotype
  • Use skin/hair findings as clues for metabolic/genetic disorders
  • Check for organomegaly (storage/metabolic disease)

Imaging choice: CT vs MRI

Brain CT

  • Pros
    • cheaper, fast, widely available
    • useful for certain conditions (e.g., calcifications; some infection-related findings such as TORCH-related calcifications)
  • Cons
    • radiation
    • lower resolution and sensitivity (may miss cortical dysplasias)

Brain MRI

  • Pros
    • higher sensitivity
    • lower/no radiation
    • better detection of subtle lesions (cortical dysplasias, hippocampal mesial sclerosis, etc.)
  • Cons
    • may require sedation
    • contraindicated with some implants
    • cost considerations

When to order EEG

  • Recommended for children with unprovoked epileptic seizure to help classify seizure type and guide medication.
  • Urgent/emergency EEG indications
    • suspected status epilepticus (convulsive or non-convulsive)
    • seizure that does not recover after a period of time
    • fluctuating altered mental status during observation
  • Not recommended solely because of family anxiety if the patient has recovered and is stable.

Case example (Rodolfo)

  • Presented with early onset episodes at 6 months:
    • disconnected state, altered consciousness, gaze deviation, non-responsiveness
  • Initial steps:
    • EEG (reported normal)
    • empiric treatment with valproic acid
  • Imaging progression:
    • CT: suggested corpus callosum issues (inconclusive)
    • MRI: showed complete agenesis of the corpus callosum and ventricular dilation
  • Expanded workup:
    • genetic evaluation
    • microarray identified a pathogenic lesion on chromosome 1q43-q44
    • diagnosed as microdeletion/disease syndrome “1q43-q44” (microd1q43-q44) (as stated)
  • Key lesson:
    • Genetic testing can end the “diagnostic odyssey,” guide prognosis/genetic counseling, reduce repeat imaging, and connect families to support resources.

Differential diagnosis: seizure vs non-epileptic paroxysmal events

  • First step: decide epileptic vs non-epileptic mimic.
  • Non-epileptic paroxysmal disorders often have:
    • abrupt onset and short duration
    • do not involve the same brain hyperexcitable mechanism
  • Practical tip: home videos from caregivers (mobile phones) can be crucial.
  • Example:
    • Infant with shaking movements but no loss of consciousness → labeled a shuddering/shaking attack (non-epileptic mimic); normal development/exam; no further studies.

Methodology / step-by-step approach (as taught in the talk)

A) At the bedside: manage the “first epileptic crisis”

Step 1: Stabilize immediately

  • If in hospital/ER: establish IV access if possible.
  • Follow emergency priorities:
    • Airway, Breathing, Circulation
    • monitoring

Step 2: Confirm epileptic seizure vs mimic

Use:

  • detailed caregiver history
  • observation of semiology (motor/non-motor, autonomic signs, automatisms, cognition changes)
  • responsiveness and post-event recovery pattern

Step 3: Classify the seizure

Determine:

  • focal vs generalized vs unknown onset
  • motor vs non-motor focal onset
  • semiology descriptors: tonic / tonic-clonic / myoclonic
  • consider EEG ictal patterns when available

Step 4: Determine provoked vs unprovoked

  • If provoked, investigate typical pediatric triggers:
    • metabolic problems, infections, intoxications, trauma, (less common) stroke
    • febrile seizures (6 months–5 years)
    • gastroenteritis/parainfectious (notably norovirus/rotavirus; seizures can occur in clusters)
  • If unprovoked, recognize higher recurrence risk and proceed with epilepsy evaluation.

Step 5: Decide on tests (general principles)

  • If truly epileptic and not clearly provoked:
    • EEG
    • Brain MRI (gold standard for lesions/subtle abnormalities)
  • CT is reserved for specific urgent indications.

B) Imaging indications (CT vs MRI)

Order emergency CT if there are red flags after the event, such as:

  • Focal neurological deficits after the event (e.g., paralysis/no movement of a body part)
  • history suggesting structural catastrophe:
    • prior trauma
    • brain tumor
  • suspicion of:
    • meningitis
    • stroke
    • intracranial hypertension

Avoid CT solely to reassure families

  • Do not order CT just for reassurance when the child recovered and there are no neurological indications (to avoid radiation).

Use MRI as the diagnostic gold standard

  • When evaluation warrants it.

C) EEG urgency rules (as described)

  • Urgent EEG if suspected:
    • convulsive status epilepticus (or when not improving)
    • non-convulsive status epilepticus
    • ongoing seizure activity without recovery
    • fluctuating mental status during observation
  • Outpatient/standard EEG for stable, recovered patients.
  • Not indicated solely due to caregiver anxiety if the child is neurologically stable.

D) If seizures do not stop: status epilepticus escalation

Definition

  • Seizure lasting ≥ 30 minutes, or
  • multiple seizures over 30 minutes without regaining consciousness

Timing/phase concept (ILAE-based)

  • Phase 1 (“time”): treat early since spontaneous cessation is less likely
  • Phase 2: control by the time window when neuronal injury risk increases
    • (windows differ by convulsive vs focal vs non-convulsive status)

Staged categories mentioned

  • Initial status: treat within first 5 minutes
  • Established status: within first 30 minutes
  • Refractory: persists after benzodiazepines and a second antiseizure medication
  • Super-refractory: continues even after additional escalation including anesthetic-type agents

Emergency medication sequence concept (general)

  • Time 0
    • protect ABC
    • monitor
    • IV line if possible
    • baseline tests after ~5 minutes
  • Use two benzodiazepine doses max
    • first dose immediately
    • second dose after ~10 minutes if persistent
  • If not controlled after ~15–30 minutes
    • give second-line antiseizure medication
    • (agents listed included valproate/levetiracetam/phenytoin/phenobarbital)
  • At 30 minutes if unresolved:
    • ICU admission
    • consider EEG monitoring if available
    • escalate with ICU anesthetic-type agents (e.g., propofol/thiopental/others depending on protocol)

Important contraindication cautions (as stated)

  • Valproate contraindications: liver disease or inborn errors of metabolism
  • Phenytoin contraindications: cardiac abnormalities (as noted)

E) Long-term management principles after the first seizure

Decide with neurology based on:

  • provoked vs unprovoked nature
  • EEG findings (focal vs generalized)
  • whether MRI was done and what lesions are present
  • patient factors: age, sex, seizure type, comorbidities

Medication approach mentioned (commonly used):

  • phenobarbital, phenytoin, valproic acid, levetiracetam

Adherence emphasis:

  • dosing often every 12 hours
  • avoid confusing dosing schedules for families
  • newer-generation medications may be limited locally.

F) When to consider genetic studies (teaching point)

Consider genetics especially when one or more apply:

  • drug-resistant epilepsy
  • epilepsy plus additional conditions, such as:
    • autism spectrum disorder
    • intellectual disability
    • global developmental delay
  • epilepsy starting before age 2
  • focal epilepsy with no lesion on MRI but family history
  • treatment resistance
  • brain malformations

Benefits highlighted:

  • ends diagnostic uncertainty
  • provides genetic counseling for future pregnancy decisions
  • may prevent repeated unnecessary imaging/testing
  • enables connection to clinical trials and support communities.

Speakers / sources featured

  • Dr. E. Chávez (main speaker)
  • Dr. Montiel (mentioned as inviting/considering participation)
  • Dr. Cabrera (recommended genetic tests; specific testing strategy referenced)
  • Carlitos (audience member/interrupting voice early)
  • Rodolfo (patient in the clinical case)
  • ILAE / ILAE (International League Against Epilepsy) (source for epilepsy definition and status epilepticus timing framework)
  • ILAA (mentioned in subtitles; appears to refer to the same International epilepsy/status epilepticus framework)
  • Spanish Society of Pediatric Emergencies (protocol source referenced for status epilepticus medication/dosing)
  • Roosevelt Hospital (availability of emergency EEG referenced)
  • Tecniscan / “3 Tesla” center (referenced for MRI capability; Barcelona context)
  • Hospital X / Hospital X (social security hospital) (context where genetics unit may be lacking)

Original video