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POST TRAUMATIC

EPILEPSY

Posttraumatic epilepsy (PTE) is a recurrent seizure


disorder that apparently results from injury to the
brain. This injury may be due to traumatic brain
injury (TBI) or to an operation on the brain.
The PTE kindling model of epilepsy postulates that
iron deposition from extravasated blood leads to
damage by free radicals, and the accumulation of
glutamate leads to damage by excitotoxicity.
Animal studies suggest that disruption of the
blood-brain barrier is likely to contribute to the
generation of seizures in PTE.

The etiology

are Severe trauma,


Penetrating head injuries, Intracranial
hematoma, Linear or depressed skull
fracture, Hemorrhagic contusion, Coma
lasting more than 24 hours, Early PTS,
History of prior TBI as it tends to be
cumulative, Focal neuroimaging or
electroencephalographic abnormalities in
the acute postinjury period, etc.

as age inrease risk of early and late seizure decrease

Clinical Presentation & Diagnostic


Consideration

Posttraumatic epilepsy (PTE) are usually partial


(focal) or generalized tonic-clonic seizure.
In physical examination no specific findings are
noted on physical examination
PTE with TBI, many patients may have
posttraumatic headaches.
Diagnostic test
Video EEG monitoring, which shows that the
nature of the seizures is psychogenic rather
than epileptic. Some frontal lobe seizures may
have bizarre features, so caution should be used
if basing the decision solely on clinical features.

Elektrolit

test, investigation of a seizure


should focus on determining whether an
intracranial bleed or a change in clinical
condition (eg, hyponatremia) has caused
the seizure
MRI or Head CT Scan, detec all pathology
(eg. Intrakranial bleed) that needs urgent
intervention.
Electroencephalography (EEG) is useful
mainly for localizing seizure foci and for
prognosticating their severity

Diffrential Diagnostic
Post traumatic seizure
Benign Childhood Epilepsy
Head injury
Phychogenic nonepileptic seizure

Treatment
IV phenytoin and sodium valproate are the
antiepileptic drugs (AEDs) of choice and are
usually effective in stopping the seizure,
along with IV benzodiazepine.
Surgical treatment is an option for PTE
refractory to medication

Pneumonia
Pneumonia is defined as an inflammation of
lung tissue due to an infectious agent.
Commonly used clinical World Health
Organization operational definition is based
solely on clinical symptoms (cough or
difficulties in breathing and tachypnoea).

Epidemiology

<5 years old

5 19 years old

30-45 / 100 children

16-20 / 100
children

> 19 years old


6-12 / 100
children

classification

Etiology
Haemophilus
BACTERIA
Haemophilus
Maraxella
BACTERIA
Maraxella

Pathophysiology

Diagnosis
Clinical findings

Treatment

*not able to drink, persistent vomiting, convulsions, lethargic or


unconscious, stridor in a calm or severe malnutrition

CASE REPORT
AS,

8 months old boy, with 8 kg of body weight and


76 cm of body height, weight/age -2<Z Score<0,
height/age -3<Z Score<-2, Weight/Height -3<Z
Score<-2 admitted to RSHAM pediatric departement
of infection unit on June 13th 2015 at 07.40 pm with
chief complaint was having seizure.

History of disease:
Patient experienced a seizure on that day, seizures 3 times, duration
10-15 minutes, Seizures experienced throughout the body, after the
seizure the patient was unconscious, seizures without fever. Last
seizures 2 weeks ago.
History of vomiting (+) since two days ago, the frequency was
3x /day. Vomiting was not projectil, volume 1/4 cup aqua what its
contents in the meal.

Loss of consiousness (+) 3 weeks ago, according to the


patient's family was not cry anymore.
Before admitted to RSHAM patients treated for falls
from motorcycles. The accident was experienced in 3
weeks prior to hospital admission. The trauma
experienced at the back of the head. After the incident
patient unconscious for 12 hours.

History of previous illness post traumatic seizure and


broncopneumonia
History of drug use was ampiciilin, gentamisin,
phenobarbital, nebule fluxotide+ventolin, and.
Paracetamol
History of imunitation BCG 4 times, hepatitis 3 times,
DPT 3 times, Measles -.

History of pregnancy was gestation age 9 month.


History , fever and diabetes during pregnancy was
not found.
History of birth was helped by doctor, baby born
through section secarea and immediately cried, body
weight 3600 kg, body length 51 cm.
History of feeding 6 month breast feeding.
Physical examination on this child of the status
showed that the lewel of consiousness is compos
mentis, GCS 15, body temperature 37, body weigt 8
kg, body length 76 cm, leng of circumtance 43,5.

Status localized:

Head: flat large fontanella, conjunctiva palpebra inferior


anemis (-/-), E/N/T normal.

Thoraks: Simetris fusiformis, retracted (-), HR:110x/minutes,


regular, murmur (-), RR: 30x/minutes, regular, ronchi (-).
Abdomen:

Ekstremities: puls:120x/minutes, regular, t/v hard, warm


akral, CRT <3, blood pressure 100/60 mmhg.

Soepel, peristaltic (+), hepar/lien not palpable.

Working diagnose was Generelized Post traumatic epilepsy


+ Broncopneumonia.
Diffrential diagnosis: Generelized post traumatic
seizure/Subdural Hematoma + Broncopneumonia.

Therapy given: - O2 2L/i nasal canule


-IVFD NaCl 0,9%, 30 gtt/i
-Ceftriaxon 250mg/12 hours.
- Phenobarbital 5 mg/KgBB/12 hours: 20 mg/12 hours in
NaCl 0,9% in 20.
-Carbamazepine 10mg/KgBB/day: 3x26 mg
- Diet 800 kkal with 18 gr protein.
- R/ X-Ray thoraks
The feature investigation plan was laboratorium Complete blood
count test, albumin, AGDA, RFT, x-ray schedel and cervical, head
CT Scan

Test

Result

Unit

Referral

Hemoglobin

11.10

g%

12.0-14.4

Erythrocyte

4.23

106/mm3

4.40-4.48

Leucocyte

7.4

103/mm3

4.5-13.5

Thrombocyte

405

103/mm3

150-450

Hematocrite

34.2

37-41

Eosinophil

10

1-6

Basophil

0.4

0-1

Neutrophil

25

37-80

Lymphocyte

54.3

20-40

Monocyte

10.3

2-8

Neutrophil absolute

1.85

103/L

2.4-7.3

Lymphocyte absolute

4.02

103/L

1.7-5.1

Monocyte absolute

0.76

103/L

0.2-0.6

Eosinophyl absolute

0.74

103/L

0.10-0.30

Basophyl absolute

0.03

103/L

,0-0.1

MCV

80.9

fL

81-95

MCH

26.2

Pg

25-29

MCHC

32.5

g%

29-31

RDW

17.1

11.6-14.8

Morphology:
Erythrocyte:
hipokromic
micrositer
Leukocyte : normal
Trombocyte :
normal

Clinical Chemistry
Test

Resul

Unit

Referral

t
Hepar
Fosfatase alkali (ALP)

176

U/L

<462

AST/SGOT

37

U/L

<38

ALT/SGPT

24

U/L

<41

Renal
Ureum
Creatinin

Carbohydrate Metabolism
Blood Glucose

79.7

mg/dL

< 200

Natrium

137

mEq/L

135-155

Kalium

4.9

mEq/L

3.6-5.5

Cloride

105

mEq/L

96-106

Other Test

Electrolite

Hemostatic function
Ferritin : 1852.00 mg/mL
(Normal: Adult=15- 300;
Child=15-240)
Fe/Iron : 36 mg/dL
(Normal:
61-157)
TIBC : 104 g/dL
(Normal:
112-346)

Follow Up
June 14th2015
S

Seizure (-), Fever (-)

Sensorium: Compos Mentis, GCS 15, Temp: 37oC.


Head :
-

Eye : light refleks (+/+), isochoric pupil, pale was found in inferior conjunctiva palpebral(+/+)

Ear : within normal range

Nose : within normal range

Mouth : pale mucous +/+

Thorax : symmetrical fusiform, retraction (-)


-

HR: 125 bpm, reguler, murmur (-)

RR : 34 bpm, reguler, wheezing (-/-), rhonchi (-/-)

Abdominal : supple, peristaltic (+)N, liver was not palpated.

Extremities : pulse 125 bpm, reguler, p/v adequate, warm acral, CRT < 3
Thorax Photo:

Generelized Post Traumatic Epilepsy + Bronchopneumonia

O2 2L/i nasal canule


IVFD NaCl 0,9%, 10 gtt/i
Ceftriaxon 250mg/12 hours.
Phenobarbital 20 mg/12 hours in NaCl 0,9% in 20.
Carbamazepine 10mg/KgBB/day: 3x26 mg
Nebule ventolin, respul +NaCl 0,9% 2,5 ml/ 8hours
Diet 800 kkal with 18 gr protein.
R/ Head CT Scan

June 15th2015
S

Seizure (-), Fever (-)

Sensorium: Compos Mentis, GCS 15, Temp: 36,7oC.


Head :
-

Eye : light refleks (+/+), isochoric pupil, pale was found in inferior conjunctiva palpebral(+/+)

Ear : within normal range

Nose : within normal range

Mouth : pale mucous +/+

Thorax : symmetrical fusiform, retraction (-)


-

HR: 124 bpm, reguler, murmur (-)

RR : 30 bpm, reguler, wheezing (-/-), rhonchi (-/-)

Abdominal : supple, peristaltic (+)N, liver was not palpated.

Extremities : pulse 124 bpm, reguler, p/v adequate, warm acral, CRT < 3
Head CT:

Generelized Post Traumatic Epilepsy + Bronchopneumonia

O2 2L/i nasal canule


IVFD NaCl 0,9%, 10 gtt/i
Ceftriaxon 250mg/12 hours.
Phenobarbital 20 mg/12 hours in NaCl 0,9% in 20.
Carbamazepine 10mg/KgBB/day: 3x26 mg
Nebule ventolin, respul +NaCl 0,9% 2,5 ml/ 8hours
Diet 800 kkal with 18 gr protein
R/EEG

June 16th2015
S

Seizure (+) , fever (-)

Sensorium: Compos Mentis, GCS 15, Temp: 37,2oC.


Head :
-

Eye : light refleks (+/+), isochoric pupil, pale was found in inferior conjunctiva palpebral(+/+)

Ear : within normal range

Nose : within normal range

Mouth : pale mucous +/+

Thorax : symmetrical fusiform, retraction (-)


-

HR: 124 bpm, reguler, murmur (-)

RR : 28 bpm, reguler, wheezing (-/-), rhonchi (-/-)

Abdominal : supple, peristaltic (+)N, liver was not palpated.

Extremities : pulse 124 bpm, reguler, p/v adequate, warm acral, CRT < 3
EEG :

Focal Post Traumatic Epilepsy + Bronchopneumonia

O2 2L/i nasal canule


IVFD NaCl 0,9%, 10 gtt/i
Ceftriaxon 250mg/12 hours.
Phenobarbital 20 mg/12 hours in NaCl 0,9% in 20.
Carbamazepine 10mg/KgBB/day: 3x26 mg
Nebule ventolin, respul +NaCl 0,9% 2,5 ml/ 8hours
Diet 800 kkal with 18 gr protein

June 17th2015
S

Seizure (-) , fever (-)

Sensorium: Compos Mentis, GCS 15, Temp: 37 oC.


Head :
-

Eye : light refleks (+/+), isochoric pupil, pale was found in inferior conjunctiva palpebral(+/+)

Ear : within normal range

Nose : within normal range

Mouth : pale mucous +/+

Thorax : symmetrical fusiform, retraction (-)


-

HR: 115 bpm, reguler, murmur (-)

RR : 24 bpm, reguler, wheezing (-/-), rhonchi (-/-)

Abdominal : supple, peristaltic (+)N, liver was not palpated.

Extremities : pulse 115 bpm, reguler, p/v adequate, warm acral, CRT < 3

Focal Post Traumatic Epilepsy + Bronchopneumonia

O2 2L/i nasal canule


IVFD NaCl 0,9%, 10 gtt/i
Ceftriaxon 250mg/12 hours.
Phenobarbital 20 mg/12 hours in NaCl 0,9% in 20.
Carbamazepine 10mg/KgBB/day: 3x26 mg
Diet 800 kkal with 18 gr protein