Kejang

1% kunjungan UGD memerlukan

perhatian dan oenyelidikan yg lebih
Benign dan self limited, atau mungkin
tanda awal penyakit yg lbh seriur atau
status epilepticus

1
 Differential diagnosis

Syncope
Migraine dgnaura
Movement disorder : Tic disorder
Startle syndrome (hyperekplexia)
Benign nocturnal myoclonus
Gangguan tidur
Gangguan Sensoris
Psikogenik: Breath-holding spells
Panic attacks
Pseudoseizure
2
Kejang Demam

3
 Definisi

Kejang Demam adalah serangan kejang pada

masa bayi atau anak, biasanya timbul antara usia
6 bulan dan 5 tahun, behubungan dgn demam,
(>38 0C rectal) tapi tanpa adanya bukti infeksi
intrakranial atau penyebab lain.

4
 Demam

Demam yang menyebabkan terjadinya kejang

Anak kejang padahal demamnya tdk terlalu tinggi
Risiko lbh tinggi kejang berulang
75% anak pada saat kejang suhunya 39 0C atau lebih
Penting menurunkan suhu tubuh kompres
Dianjurkan The important of lowering body
temperature has been stressed. Reduction of
temperature by sponging or tepid bath is usually
advised

5
 Usia

Usia berhubungan dgn terjadinya kejang

Makin muda usia makin tinggi risiko
terjadinya kejang (40 versus 20%)

6
 Age

SSP immatur peka terhadap terjadinya

kejang.
Otak immatur Eksitabilitas NMDA
meningkat of enhanced excitability NMDA
GABA menurun
Kerusakan membran melepaskan zat
excitotoxic spt glutamat, yg mencetuskan
kejang

7
 Faktor genetik

Faktor genetik memegang peranan panting.

Risiko lebih tinggi bila ada riwayat keluarga
(25-40 %)

8
Kejang demam Kompleks

Salah satu atau lebih dari:

> satu bangkitan kejang dalam 24 jam
Lamanya lebih 15 Menit
Focal Motorik

9
Fakta tentang Kejang Demam
2-4% populasi anak( 6 bln- 4 thn)
80% kejang demam sederhana
20% Kejang demam kompleks
8% berakhir> 15 min

16% rekuren dlm 24 jam

2-4% menjadi epilepsi

Biasanya terjadi antara umur 17 23 bln
Laki> perempuan
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Table 12-1. Differences Between Febrile Seizures and
Seizures due to Febrile Brain Disease
Seizures in Febrile
Febrile Convulsions Brain Disease
Genetic predispo- May be strong Mostly minor or insignificant
sition to seizures
Type of seizure Tonic-clonic Focal or focal -generalised
Duration of seizure Mostly 1-3 min, seldom Often prolonged, 10 min to
prolonged hours (status-like)

Clinical setting in At the onset of a febrile In a variety of CNS infections

which seizures disease, mostly upper (encephalitis, meningoence
occur respiratory illness phalitis)

Type of underlying None Various types of inflammatory

cerebral pathology vascular changes and edema
Postictal neurologic Very uncommon Concious Common
(Todds paralysis)
EEG Rapidly normalies after Abnormal throughout febrile
convulsion episode

(Niedermeyer E: Epilepsy Guide: Diagnosis and Treatment of Epileptic Seizure Disorders , 1985)
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 Work Up of Child with a Febrile Seizure

Rawat inap Jarang diperlukan

kecuali kejang demam kompleks

Evaluasi penyebab demam Selalu

Lumbar Puncture Strongly consider:

infant < 12 mo after first seizure
Should be consider:
children between 12-18 mo

Not routinely beyond 18 mo

EEG tidak perlu

12
 Tatalaksana
1. prevention of prolonged seizure
2. intermittent prophylaxis
3. continuous prophylaxis

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 Febrile Seizure

Rectal Diazepam in sol.

0.5 mg/kg

Repeat Diazepam in sol.

0.5 mg/kg

Hospitalization

Diazepam i.v.
0.5 mg/kg
Up to 2-3 mg/kg (total dose)

Phenytoin

Fig. 6. Flow chart for emergency treatment of short and prolonged febrile seizures
At home and in the hospital (Knudsen FU, 1996)
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 Febrile Status epilepticus

Demam berkepanjangan menyebabkan

hipoksia, edema otak, dan asidosis
Prolonged fits cause progressive cerebral
hypoxia,
25% of status epilepticus pada anak. 40% of
pada serangan pertama kejang.
2/3 of anak yy punya kelainan neurologik
akan mengalami kejang demam lagi , 1/3nya
akan mengalami status epileptikus lagi

15
Recurrence risk (%)
controls

40

30

Short-term prophylaxis
20

10

6 12 18
Fig. 8. The cumulative 6,12 and 18 month recurrence rates after the first febrile seizure
(FC) in children given intermittent diazepam prophylaxis (lower graph) or diazepam alone
In the event of seizures recurrence (upper graph). The efficacy of intermittent diazepam
Prophylaxis is evident. 16
 Rectal or oral diazepam

Intermittent diazepam prophylaxis efektif

mengurangi rekurensi
Dosis profilaksis 0,3 mg/kg oral, or 0,5 mg/kg
rektal tiap 8 jam bila suhu > 38,50 C.

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 Continuous prophylaxis

phenobarbitone mengurangi separuhnya risiko

rekurensi

Rekurensi 12.8% dengan valproate, 13% dengan

phenobarbital, dan 34% bila tidak di profilaksis

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 Konsensus 2005

Daily continuous anticonvulsant (satu atau lebih)

Adanya kelainan neurologik(CP, MR, Microcephaly)

Riwayat Kejang lama (>15 min)

Riwayat kejang fokal

Pertimbangkan daily continuous anticonvulsant

Kejang demam multipel (> 2x kejang dlm 24 jam)

Kejang terjadi sebelum usia 1 tahun

Sering2 kejang demam (4 atau lebih dalam 12 jam)

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 Normal children (most children)

Epilepsy 2-4%,3% on average)

Four or 6 times higher than the incidence of

epilepsy in the general child population
Febrile convulsions

Dyskinesia and
(uncommon)
incoordination

Learning and
behavioral (uncommon)
disorders

Mental retardations (rare)

Fig. Natural history of febrile convulsions

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 Status Epilepticus

Kejang tunggal atau multipel

> 30 menit dimana kesadaran
tidak pernah pulih

21
 Klasifikasi klinis SE

Generalized convulsive SE (GCSE)

Tonic-clonic

Clonic / Tonic
Partial SE
Simple partial
Complex partial SE (CPSE)

Behera CMK, et al, MJAFI 2005;61:

174-178

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 Table. The physiologic and neurologic events of
seizures vs. status
Parameter Seizures Status Epilepticus Complications
Blood Pressure increased decreased Shock
PaO2 decreased decreased hypoxia

pH decreased decreased or no Acidosis

Temperature increased increased hyperpyrexia

Pulmonary Secretions increased increased atelectasis

K+ increased increased arrhythmias
CPK and Myoglobin decreased increased Renal fallure
CBF increased increased (200%) intracranial bleed
(550%)
CMRO2 increased increased (300%) nuronal death
(300%)
Blood Glucose increased decreased neuronal injury

( Fuhman B and Zimmerman J ed. 1991. p 596)

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 Acute Management of Status
Epilepticus

Airway
High Flow oxygen

IV access

Diazepam 5 min
0.25 mg/kg IV/IO

Diazepam
0.25 mg/kg IV/IO 5 min

Phenytoin
20 mg/kg IV
5 min

Phenobarbitone 5 min
20 mg/kg IV

If seizure persists > 10 min after phenobarbitone,

Treat as Refractory Status Epilepticus
Neurology & PICU consult
Admission to PICU 24
 Refractory Status Epilepticus*

Place EEG monitorand central lines

Monitor blood preasure
Keep ventilatory support ready

Midazolam 0.15 mg/kg stat, infusion 0.75-18 ug/kg/minute or

Diazepam 0.3 mg/kg stat, infusion 0.01-0.04 mg/kg/min or
With ventilatory support
Propofol 1-3 mg/kg stat, infusion 2-10 mg/kg/hr or
Penobarbital 5-15 mg/kg stat, infusion 0.5-5 mg/kg/hr or
Thiopental infusion 3-4 mg/kg stat, infusion 1-10 mg/kg/min

*Best managed in the pediatric intensive care unit

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