Fits, Faints, and Funny Turns - Comprehensive Notes

FITS, FAINTS AND FUNNY TURNS

Fits, Faints, and Funny turns represent paroxysmal events in children, common in 25% of pediatric admissions.
Includes epileptic seizures (Fits) and Paroxysmal Non-Epileptic Events (PNE), commonly called ‘Faints and funny Turns’.
PNEs are transient episodes of altered consciousness or awareness, difficult to differentiate from epileptic seizures, leading to misdiagnosis of epilepsy in 30% of cases.

History: Detailed history is crucial.
- Obtain information from eyewitnesses and the patient.
- Videos are helpful.
- Detailed description of the event:
  - Before: triggers, aura, sweating, palpitations.
  - During: eye, face, tongue-bite, limbs, incontinence.
  - After: weakness, confusion, LOC, drowsiness.
- Recurrence: frequency, similarity.
- Association with sleep, stress, exertion, medication.
- Birth history, past medical history, developmental history, medication history.
- Family history (cardiac, neurological, sudden death).
Examination
- Vital signs (including standing and supine BP).
- Full examination:
  - Detailed neurology with fundoscopy.
  - Detailed cardiovascular examination.
  - Look for injury/NAI signs.
Investigations
- All children with paroxysmal events require:
  - Blood glucose.
  - BP (supine and standing).
  - ECG.
- Do not refer for an EEG to ‘rule in’ or ‘rule out’ epilepsy after a single paroxysmal event.

‘Fits’ and ‘seizures’ are often used interchangeably.
‘Fits’ (or Convulsions) are the physical manifestation of the electrical disturbance (seizure) in the brain.
Seizures can have several causes: structural malformations, infections, dyselectrolytemia, trauma, fever.
Epilepsy Definition:
- Recurrent (2 or more) unprovoked epileptic seizures occurring >24 hours apart.
- 1 unprovoked seizure and high probability of further seizures.
- Diagnosis of an epilepsy syndrome.

Generalized Seizures
- Tonic-clonic
- Atonic (Drop-attacks, helmets)
- Myoclonic (clumsiness, drop things, clusters in early morning)
- Absence (Inattention episodes, 3Hz spike and wave)
Focal Seizures
- Focal Seizures with preserved consciousness
- Focal Seizures with Impaired consciousness
- Focal Seizures with secondary generalization
Unclassified Seizures
Epilepsy Syndromes: common ones with childhood onset:
- Infantile spasms (West syndrome)
- Lennox-Gastaut Syndrome (LGS)
- Childhood Absence epilepsy
- Dravet Syndrome
- Benign Rolandic Epilepsy
- Landau-Kleffner Syndrome.

These include:

Most common childhood seizure disorder
Unique response of the young childhood brain to fever
Most common age: 6 months – 5 years
Rigors are a close differential diagnosis for febrile seizures
For simple febrile seizures, reassurance and antipyretics are usually sufficient, along with educating the parents on how to manage if the fit recurs.

4-month-old boy
Born at term, normal vaginal delivery, no complications
Over the last 2 weeks, developed episodes involving extension of the arms and neck, with flexion of the legs, lasting a few seconds.

Infantile spasms (aka WEST SYNDROME) is a rare and particularly severe Epilepsy syndrome that starts in the 1st year of life.
Sudden jerking movements of arms, legs, and trunk (like a startle reflex) (often misdiagnosed).
Classical EEG: hypsarrhythmia.
Lose already achieved milestones (Neuroregression).
Multiple causes: most common is tuberous sclerosis.
Look for other features, dysmorphism, skin changes.
STOP is a mnemonic promoted by ISAN (infantile spasms action network) to use as a starting point to recognize infantile spasms.
Treatment: Vigabatrin +/- Prednisolone.
Prognosis: Can develop other seizure types, cognitive delays, autism later.

Myoclonic Seizure

Very common Epilepsy syndrome
Usually starts between 12-18 years (Girls > Boys)
Can have Myoclonic / Tonic-clonic / Absence seizures
Usually present with clumsiness/dropping things - so often missed.
Episodes occur in clusters, usually after waking up
Worse when tired, sleep-deprived, after taking alcohol
Treatment: Sodium valproate {2nd line - Levetiracetam / Lamotrigine / Topiramate}

Repetitive jerking movements of the extremities that occur irregularly during NREM sleep in healthy babies in the first 2-3 months of life.
Usually benign, and reassurance of carers is all that is needed.
Important to differentiate it from myoclonic seizures.

BNSM	MYOCLONIC JERKS
Occurs only during sleep	Can occur when asleep/awake
Movement ceases on awakening	Awakening does not stop myoclonus
No epileptiform activity on EEG	Interictal EEG is often abnormal
No resolution/worsened by antiepileptics	Antiepileptics moderately effective

Blue/Cyanotic breath-holding
- Most common type.
- Triggered by anger, frustration, and intense crying beforehand.
- Child holds his breath in expiration.
- May turn blue.
- Become stiff/body may jerk/lose consciousness for 1-2 min/recovers quickly.
- No specific treatment, grow out of it, sometimes have iron deficiency.
Reflex anoxic seizures
- Triggered by sudden fright, pain, or strong emotion.
- Results in brief stoppage of heart due to excessive vagus nerve activity.
- Child usually turns pale (White breath-holding).
- If too frequent, glycopyrrolate/atropine can be used here.

Definition: Convulsive status epilepticus is a seizure that continues for > 5 mins, so treatment is usually started after 5 mins.
Look for red flags.
ABC, give oxygen, check blood glucose early.
5 mins: 1st Benzodiazepine.
10 mins: 2nd benzodiazepine. (Max 2 doses of BZD).
15-35 min: 2nd line agents (Levetiracetam/phenytoin/phenobarb).
CALL anesthetist and PICU.
20-40 min: Intubation + Ventilation with anesthesia or 2ND /3RD line agents.