5 - Seizures Flashcards
Do pts with epileptic EEG’s always have symptoms?
Nope some are asymptomatic
Looks like a seizure but not a true seizure?
Some seizure-like episodes may be due to causes other than abnormal brain electrical activity, such attacks are not true seizures
What is epilepsy?
Clinical condition where individual is subject to recurrent seizures
More excitable brain with lower seizure threshold
Recurrent seizures but not an epileptic?
If the cause is a reversible condition i.e. etoh withdrawal, hypoglycemia, or other metabolic problem
This is not a seizure
Primary vs secondary seizure?
Primary/idiopathic: no known cause
Secondary/symptomatic: ID’d condition like mass lesion, previous head injury, or stroke
Reactive seizure?
Reaction to something bad like:
- convulsant drugs
- metabolic disturbance
- sharp blow to head
- etc
Cause seizure in otherwise normal person
Usually self limiting
Provoked and unprovoked seizure?
Provoked:
- Acute precipitating event w/in 7 days
Unprovoked:
- some guy just breaks in and pees on your rug
Status epilepticus?
Status epilepticus: seizure >5min or 2+ seizures w/out regaining consciousness
Refractory status epilepticus?
Refractory status epilepticus: persistent seizure activity despite IV admin of 2 antiepileptic agents
Types of Generalized seizures?
Tonic-clonic (grand mal)
Absence (petit mal)
(Consciousness is always lost)
Partial (focal) seizure?
Simple (no LOC)
Complex (consciousness impaired)
Partial w secondary generalization (jackson march)
“Other” seizures?
Myoclonic
Tonic
Clonic
Atonic
What is a jackson march or jacksonian seizure?
Only occurs on one side of body; progresses in a predictable pattern from twitching or tingling sensation or weakness in finger, big toe, or corner of mouth, then “marches” over a few seconds to entire hand/foot/face
What part of the brain is involved during a generalized seizure?
It is thought to be nearly simultaneous activation of the entire cerebral cortex
Generalized seizures begin with?
Abrupt loss of consciousness, may be the only clinical manifestation (absence attacks)
tonic-clonic (grand mal) seizure phases
Tonic phase: pt gets rigid
- trunk and extremities extend an pt falls to ground
Clonic phase: coarse trembling that evolves into symmetric rhythmic jerking of trunk and extremities
Describe grand mal seizure
Move seizure
- Tonic phase followed by clonic phase
- Pt is usually apneic/cyanotic
- urination
- vomiting
- pt becomes flaccid and unconscious
- deep rapid breathing
- consciousness returns with postictal confusion and fatigue
How long does grand mal seizure usually last?
Generally 60-90 sec, though bystanders usually overestimate the time
Describe generalized absence (petit mal) seizure
Very brief (seconds)
- sudden altered conscious
- no change in postural tone
- appear confused, detached or withdrawn
- twitching of eyelids
may not respond to voice and loqse consciousness
Post petit mal?
Attack ceases abruptly and pt typically resumes what they were doing
No postictal symptoms
Classic generalized absence seizure pt?
School-aged children
- parents/teachers think they are daydreaming or not paying attention
Can occur up to 100 times/day
Prognosis for petit mal seizure?
They generally resolve as pt gets older
Generalized absence seizure in adults?
Probably not, more likely minor complex partial seizure and should not be termed absence
This matters b/c tx is different
Partial (focal) seizure?
Begin in a localized region of brain
May remain there or move and mimic generalized seizure
Can be bad enough that an EEG is required to differentiate
Focal seizures symptoms and locations
Motor cortex
Occipital focus
Medial temporal lobe
Motor: Unilateral tonic or clonic moments limited to one extremity
Occipital focus: visual symptoms
Medial temporal: bizarre olfactory or gustatory hallucinations
Initial symptoms of attacks?
Sensory phenomena, known as auras, are often the initial symptoms of attacks
that then become more widespread, termed secondary generalization
Complex focal seizure?
Focal seizure where consciousness or mentation is affected
Often caused by focal discharge in temporal lobe
Partial (focal) complex seizures are also commonly referred to as?
Temporal lobe seizures
Complex focal seizures are often misdiagnosed as?
Psych problems
Symptoms of complex focal seizure?
- Automatisms
- Visceral symptoms
- Hallucinations
- Memory disturbances
- Distorted perception and affective disorders
I.e. “weird stuff” pill rolling, repetitive movements etc
automatisms?
Lip smacking
Fiddling with clothing
Repeating short phrases
unconscious behaviors
Visceral symptoms with partial/focal seizures?
“Butterflies” rising up from epigastrium
Psychiatric symptoms of partial/focal seizures include fear, paranoia, depression, elation or ecstasy, this led to them being called?
Psychomotor seizures
Name is no longer preferred as it causes confusion
1st step in doing a hx for a seizure?
Determine if it was actually a seizure
Get through history and witness descriptions
Specific symptoms that help ID seizures?
Aura’s Abruptness of onset The progression of motor activity Loss of bowel/bladder Oral injury Localized or Generalized movements Unilateral or symmetric
Duration of symptoms
Postictal confusion/lethargy
If the pt is a known epileptic you should?
Clarify the baseline seizure pattern
Compare this one to the baseline
ID the precipitating factors
Common precipitating factors?
- missing meds
- alterations in meds
- sleep deprivation
- infection
- exercise
- electrolyte disturbance
- ETOH/substance use/withdrawl
Indications of previous unwitnessed seizures?
- unexplained injuries,
- nocturnal tongue biting
- enuresis
Chart on
Slide on 26 has secondary seizure causes
Initial exam post seizure should look for?
Should focus on checking for injuries
Posterior shoulder dislocation is easily overlooked
Besides checking for injuries the PE must also include?
Complete neurologic exam and subsequent serial exams
Track the LOC
Todd’s paralysis?
Transient focal deficit (unilateral) following a simple/complex focal seizure
Usually resolves w/in 48hrs
Symptomsm that help clue you into seizures over seizure mimicking conditions?
Abrupt onset/termination
Lack of recall
Purposeless movements
Postictal confusion/lethargy
DDx syncope signs?
Prodrome: lightheadedness, diaphoresis, nausea and tunnel vision
Cardiac syncope
No postictal symptoms
Pseudoseizures?
Psychogenic seizures often associated with: conversion disorder, panic disorder, psychosis, impulse control disorder, munchausen syndrome or malingering
Often bizarre and highly visible
Symptoms of pseudoseizure?
Able to protect self from noxious stimuli
Side to side head thrashing
Rhythmic pelvic thrusting
Clonic extremity motion that are alternating rather than symmetric
May stop on command
Pseudoseizures will not have? (Diagnostic studies)
Positive EEG
Lactic acidosis
Elevated prolactin level
Another condition that is frequently preceded by aura?
Migraine
MC aura is scintillating scomotoma
Labs you should order for seizure pts?
Well documented epileptics:
- glucose
- pertinent anticonvulsant med level
New onset seizure:
- glucose
- BMP
- lactate
- calcium
- Mg2+
- pregnancy
- toxicology studies
Common lab findings with seizures?
Lactate-driven, wide anion gap metabolic acidosis
- usually clears w/in 30 min
Prolactin elevated for 15-60 min
Seizure imaging?
Head CT (1st seizure) to look for structural lesion
X-ray:
- injury
- primary/metastatic tumor
Any radiographs needed for injury diagnosis
LP for seizures?
If pt has acute seizure and is
- febrile
- immunocompromised
- subarachnoid hemorrhage is suspected (with normal CT)
EEG for seizure?
Great for diagnosis but not really an ED thing
If they symptoms are persistent get them to neuro
Uncomplicated seizure acute care?
Supportive
- turn head to side
- stay out of the way
We dont usually need to ventilate or give meds during uncomplicated seizure
Uncomplicated seizures that last more than 5 min?
This is Status epilepticus; need more aggressive interventions
What usually causes seizures in epileptics?
They dont take their meds
1st unprovoked seizure, how long are you getting admitted for?
Jk the guidelines recommend not admitting these patients as long as:
- normal neuoro
- no comobidities
- normal diagnostic testing
- normal mental status
Anticonvulsants for 1st seizure?
Again no, not for the 1st one
But if we need to give meds, we can defer anti-epileptic meds to the outpatient setting pending further studies, EEG and MRI
What about 2nd seizure?
Now you’re getting admitted
Recommendations for pts with 1st seizure?
Dont go swimming or work on electrical systems
No driving (this is not a choice) until cleared by neurologist or primary care physician
Why are HIV pts more prone to seizures?
This commiunity has more incidence of:
- Mass lesions
- encephalopathy
- herpes zoster
- toxoplasmosis
- cryptococcus
- neurosyphilis
- meningitis
All of which increase likelihood of seizures
HIV pt has seizure, what tests are required?
Non-contrast CT if negative then do a lumbar puncture to look for CNS infection
If still nothing is found get a contrast enhanced head CT or MRI
Women beyond 20 weeks of gestation with seizures in the presence of hypertension, edema, proteinuria is known as?
Eclampsia
Tx for eclampsia?
Magnesium sulfate
> 50% reduction in recurrence of seizures and lower incidence of pneumonia, ICU admission and assisted ventilation
(When compared to diazepam and phenytoin)
Why are alcoholics more likely to get seizures?
- Withdrawl
- missed meds
- sleep deprivation
- more head injuries
- toxic co-ingestion
- electrolyte abnormalities
Benzo’s and alcoholic seizures?
Benzo’s used to manage withdrawal symptoms will also prevent seizures
- But the doses required are very large and given in escalating fashion
You have to already have epilepsy to get status epilepticus right?
False
- can be your fist time
(Did i just sound like a DARE class right there? Weed can kill you, even if you dont take it!!!! Dun dun duuuunnnnn)
MC causes of status epilepticus?
- subtherapeutic antiepileptic levels
- preexisting neuro conditions
- CNS infection
- Trauma
- hemorrhage
- stroke
- anoxia/hypoxia
- metabolic abnormalities
- ETOH/Drugs (intoxication or withdrawal)
Epilepsia partialis continua?
Focal tonic-clonic seizure activity with normal alertness that MC affects the distal leg or arm
What is nonconvulsive status epilepticus?
Seizure in the brain but not in the body
The patient is comatose or fluctuating abnormal mental status or confusion but no overt seizure activity is present
Findings that suggest nonconvulsive status epilepticus?
Prolonged post-ictal period after generalized seizure
Subtle motor signs (twitching, blinking)
Fluctuating mental status
Unexplained stupor or confusion in elderly
Tx for status epilepticus?
IV lorazepam: 2mg (0-.1mg/kg max)
Or
IV diazepam 10-20mg
+ 1 of the following
- fosphenytoin: 20PE/kg at 150mg/min
- phenytoin: 20mg/kg at 50mg/min
- levtriacetam: 2000-4000mg
Tx for refractory status epilepticus?
Tx Goal is <30 min
IV midazolam (o.2 mg/kg loading then 0.05-2mg./kg/hr
Or IV propofol (1mg/kg, then 1-10mg/kg/hr; or ketamine 5mg/kg.hr)
Or
IV phenobarbital 20mg/kg at 50-75mg/min
Other than meds what is a refractory status epilepticus pt getting?
Intubation
Neuro ICU admission
Continuous EEG monitoring
Phenytoin cannot be given with?
Glucose containing solutions, must be given with normal saline
What type of paralytic agent is preferred for intubation?
A short acting one, we dont want to mask the ongoing seizure activity
Dont forget to check for ___ with status epilepticus?
Glucose
If bacterial meningitis or encephalitis is the suspected cause you should?
Give empiric antibiotic or antiviral therapy
Dont do a LP!!!
Status epilepticus can induce what fluctuations in labs?
Brief peripheral leukocytosis
CSF pleocytois (increased WBC)
Radiology for status epilepticus?
No, they cant get them while seizing
Lorezapam and diazepam doses for status epilepticus?
Lorazepam 2-4mg
Diazepam 5-10mg
Equally effective
Big difference between lorazepam and diazepam?
Lorazepam has slightly slower onset (3 min, valium is 2) but the duration is much longer (12-24hrs vs 15-60 min) and has fewer recurrences
DOC for status epilepticus?
IV lorazepam
Works better than phenytoin or phenobarbital as initial drug
Drugs for established status epilepticus?
You follow the benzos with longer acting drugs
- fosphenytoin
- phenytoin
- levetiracetam
- valproate
- lacosamide
Loading dose for fosphenytoin?
20 PE/kg infused at 150 PE/min over 10-15 min
Or give it IM
Why dont we like valproic acid?
It works well but it has a black box for hepatic failure and pancreatitis
Cannot be given with phenytoin
This drug is not approved by FDA but is rapidly becoming the first line for established status epilepticus
What is levetiracetam?
Current recommendations for status epilepticus refractory?
If after 2 anticonvulsants and 60 minutes you cant fix them then we give:
Propofol
Midazolam
Barbituates (phenobarb or pentobarb)
And possibly HOTN meds to fix the side effects of this coctail
SE refractory propofol dose?
2-10mg/kg/h titrated up to seizure cessation
Short 1/2 life so can be dc once they stop
What is the risk of high dose propofol?
> 40mg/kg/h pts are at increased risk for hemodynamic instability
- HOTN
- propofol infusion syndrome
What is midazolam and what is the dose?
Its a benzo
Start at 0.05 - 0.4mg/kg/h and titrate up till they quit twitching
3rd line drugs for SE refractory?
Barbituates
- phenobarbital: 20mg/kg/IV
- pentobarbital
Ketamine
- bolus 0.5-4.5mg/kg
- infusion of 5mg/kg/h
May be considered but watch for respiratory depression and HOTN
PVT Joker: I looked forward to meet interesting and stimulating people from a ancient culture…
and kill them
