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Senior - E Med > 5 - Seizures > Flashcards

5 - Seizures Flashcards

1
Q

Do pts with epileptic EEG’s always have symptoms?

A

Nope some are asymptomatic

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2
Q

Looks like a seizure but not a true seizure?

A

Some seizure-like episodes may be due to causes other than abnormal brain electrical activity, such attacks are not true seizures

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3
Q

What is epilepsy?

A

Clinical condition where individual is subject to recurrent seizures

More excitable brain with lower seizure threshold

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4
Q

Recurrent seizures but not an epileptic?

A

If the cause is a reversible condition i.e. etoh withdrawal, hypoglycemia, or other metabolic problem

This is not a seizure

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5
Q

Primary vs secondary seizure?

A

Primary/idiopathic: no known cause

Secondary/symptomatic: ID’d condition like mass lesion, previous head injury, or stroke

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6
Q

Reactive seizure?

A

Reaction to something bad like:

  • convulsant drugs
  • metabolic disturbance
  • sharp blow to head
  • etc

Cause seizure in otherwise normal person

Usually self limiting

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7
Q

Provoked and unprovoked seizure?

A

Provoked:
- Acute precipitating event w/in 7 days

Unprovoked:
- some guy just breaks in and pees on your rug

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8
Q

Status epilepticus?

A

Status epilepticus: seizure >5min or 2+ seizures w/out regaining consciousness

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9
Q

Refractory status epilepticus?

A

Refractory status epilepticus: persistent seizure activity despite IV admin of 2 antiepileptic agents

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10
Q

Types of Generalized seizures?

A

Tonic-clonic (grand mal)

Absence (petit mal)

(Consciousness is always lost)

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11
Q

Partial (focal) seizure?

A

Simple (no LOC)

Complex (consciousness impaired)

Partial w secondary generalization (jackson march)

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12
Q

“Other” seizures?

A

Myoclonic

Tonic

Clonic

Atonic

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13
Q

What is a jackson march or jacksonian seizure?

A

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

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14
Q

What part of the brain is involved during a generalized seizure?

A

It is thought to be nearly simultaneous activation of the entire cerebral cortex

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15
Q

Generalized seizures begin with?

A

Abrupt loss of consciousness, may be the only clinical manifestation (absence attacks)

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16
Q

tonic-clonic (grand mal) seizure phases

A

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

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17
Q

Describe grand mal seizure

A

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
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18
Q

How long does grand mal seizure usually last?

A

Generally 60-90 sec, though bystanders usually overestimate the time

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19
Q

Describe generalized absence (petit mal) seizure

A

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

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20
Q

Post petit mal?

A

Attack ceases abruptly and pt typically resumes what they were doing

No postictal symptoms

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21
Q

Classic generalized absence seizure pt?

A

School-aged children
- parents/teachers think they are daydreaming or not paying attention

Can occur up to 100 times/day

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22
Q

Prognosis for petit mal seizure?

A

They generally resolve as pt gets older

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23
Q

Generalized absence seizure in adults?

A

Probably not, more likely minor complex partial seizure and should not be termed absence

This matters b/c tx is different

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24
Q

Partial (focal) seizure?

A

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

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25
Q

Focal seizures symptoms and locations

Motor cortex
Occipital focus
Medial temporal lobe

A

Motor: Unilateral tonic or clonic moments limited to one extremity

Occipital focus: visual symptoms

Medial temporal: bizarre olfactory or gustatory hallucinations

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26
Q

Initial symptoms of attacks?

A

Sensory phenomena, known as auras, are often the initial symptoms of attacks
that then become more widespread, termed secondary generalization

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27
Q

Complex focal seizure?

A

Focal seizure where consciousness or mentation is affected

Often caused by focal discharge in temporal lobe

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28
Q

Partial (focal) complex seizures are also commonly referred to as?

A

Temporal lobe seizures

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29
Q

Complex focal seizures are often misdiagnosed as?

A

Psych problems

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30
Q

Symptoms of complex focal seizure?

A
  • Automatisms
  • Visceral symptoms
  • Hallucinations
  • Memory disturbances
  • Distorted perception and affective disorders

I.e. “weird stuff” pill rolling, repetitive movements etc

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31
Q

automatisms?

A

Lip smacking
Fiddling with clothing
Repeating short phrases

unconscious behaviors

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32
Q

Visceral symptoms with partial/focal seizures?

A

“Butterflies” rising up from epigastrium

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33
Q

Psychiatric symptoms of partial/focal seizures include fear, paranoia, depression, elation or ecstasy, this led to them being called?

A

Psychomotor seizures

Name is no longer preferred as it causes confusion

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34
Q

1st step in doing a hx for a seizure?

A

Determine if it was actually a seizure

Get through history and witness descriptions

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35
Q

Specific symptoms that help ID seizures?

A 
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

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36
Q

If the pt is a known epileptic you should?

A

Clarify the baseline seizure pattern

Compare this one to the baseline

ID the precipitating factors

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37
Q

Common precipitating factors?

A
  • missing meds
  • alterations in meds
  • sleep deprivation
  • infection
  • exercise
  • electrolyte disturbance
  • ETOH/substance use/withdrawl
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38
Q

Indications of previous unwitnessed seizures?

A
  • unexplained injuries,
  • nocturnal tongue biting
  • enuresis
39
Q

Chart on

A

Slide on 26 has secondary seizure causes

40
Q

Initial exam post seizure should look for?

A

Should focus on checking for injuries

Posterior shoulder dislocation is easily overlooked

41
Q

Besides checking for injuries the PE must also include?

A

Complete neurologic exam and subsequent serial exams

Track the LOC

42
Q

Todd’s paralysis?

A

Transient focal deficit (unilateral) following a simple/complex focal seizure

Usually resolves w/in 48hrs

43
Q

Symptomsm that help clue you into seizures over seizure mimicking conditions?

A

Abrupt onset/termination
Lack of recall
Purposeless movements
Postictal confusion/lethargy

44
Q

DDx syncope signs?

A

Prodrome: lightheadedness, diaphoresis, nausea and tunnel vision

Cardiac syncope

No postictal symptoms

45
Q

Pseudoseizures?

A 
Psychogenic seizures often associated with:
conversion disorder, 
panic disorder, 
psychosis, 
impulse control disorder, 
munchausen syndrome or 
malingering

Often bizarre and highly visible

46
Q

Symptoms of pseudoseizure?

A

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

47
Q

Pseudoseizures will not have? (Diagnostic studies)

A

Positive EEG
Lactic acidosis
Elevated prolactin level

48
Q

Another condition that is frequently preceded by aura?

A

Migraine

MC aura is scintillating scomotoma

49
Q

Labs you should order for seizure pts?

A

Well documented epileptics:

  • glucose
  • pertinent anticonvulsant med level

New onset seizure:

  • glucose
  • BMP
  • lactate
  • calcium
  • Mg2+
  • pregnancy
  • toxicology studies
50
Q

Common lab findings with seizures?

A

Lactate-driven, wide anion gap metabolic acidosis

  • usually clears w/in 30 min

Prolactin elevated for 15-60 min

51
Q

Seizure imaging?

A

Head CT (1st seizure) to look for structural lesion

X-ray:

  • injury
  • primary/metastatic tumor

Any radiographs needed for injury diagnosis

52
Q

LP for seizures?

A

If pt has acute seizure and is

  • febrile
  • immunocompromised
  • subarachnoid hemorrhage is suspected (with normal CT)
53
Q

EEG for seizure?

A

Great for diagnosis but not really an ED thing

If they symptoms are persistent get them to neuro

54
Q

Uncomplicated seizure acute care?

A

Supportive

  • turn head to side
  • stay out of the way

We dont usually need to ventilate or give meds during uncomplicated seizure

55
Q

Uncomplicated seizures that last more than 5 min?

A

This is Status epilepticus; need more aggressive interventions

56
Q

What usually causes seizures in epileptics?

A

They dont take their meds

57
Q

1st unprovoked seizure, how long are you getting admitted for?

A

Jk the guidelines recommend not admitting these patients as long as:

  • normal neuoro
  • no comobidities
  • normal diagnostic testing
  • normal mental status
58
Q

Anticonvulsants for 1st seizure?

A

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

59
Q

What about 2nd seizure?

A

Now you’re getting admitted

60
Q

Recommendations for pts with 1st seizure?

A

Dont go swimming or work on electrical systems

No driving (this is not a choice) until cleared by neurologist or primary care physician

61
Q

Why are HIV pts more prone to seizures?

A

This commiunity has more incidence of:

  • Mass lesions
  • encephalopathy
  • herpes zoster
  • toxoplasmosis
  • cryptococcus
  • neurosyphilis
  • meningitis

All of which increase likelihood of seizures

62
Q

HIV pt has seizure, what tests are required?

A

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

63
Q

Women beyond 20 weeks of gestation with seizures in the presence of hypertension, edema, proteinuria is known as?

A

Eclampsia

64
Q

Tx for eclampsia?

A

Magnesium sulfate

> 50% reduction in recurrence of seizures and lower incidence of pneumonia, ICU admission and assisted ventilation
(When compared to diazepam and phenytoin)

65
Q

Why are alcoholics more likely to get seizures?

A
  • Withdrawl
  • missed meds
  • sleep deprivation
  • more head injuries
  • toxic co-ingestion
  • electrolyte abnormalities
66
Q

Benzo’s and alcoholic seizures?

A

Benzo’s used to manage withdrawal symptoms will also prevent seizures
- But the doses required are very large and given in escalating fashion

67
Q

You have to already have epilepsy to get status epilepticus right?

A

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)

68
Q

MC causes of status epilepticus?

A
  • subtherapeutic antiepileptic levels
  • preexisting neuro conditions
  • CNS infection
  • Trauma
  • hemorrhage
  • stroke
  • anoxia/hypoxia
  • metabolic abnormalities
  • ETOH/Drugs (intoxication or withdrawal)
69
Q

Epilepsia partialis continua?

A

Focal tonic-clonic seizure activity with normal alertness that MC affects the distal leg or arm

70
Q

What is nonconvulsive status epilepticus?

A

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

71
Q

Findings that suggest nonconvulsive status epilepticus?

A

Prolonged post-ictal period after generalized seizure

Subtle motor signs (twitching, blinking)

Fluctuating mental status

Unexplained stupor or confusion in elderly

72
Q

Tx for status epilepticus?

A

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
73
Q

Tx for refractory status epilepticus?

A

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

74
Q

Other than meds what is a refractory status epilepticus pt getting?

A

Intubation

Neuro ICU admission

Continuous EEG monitoring

75
Q

Phenytoin cannot be given with?

A

Glucose containing solutions, must be given with normal saline

76
Q

What type of paralytic agent is preferred for intubation?

A

A short acting one, we dont want to mask the ongoing seizure activity

77
Q

Dont forget to check for ___ with status epilepticus?

A

Glucose

78
Q

If bacterial meningitis or encephalitis is the suspected cause you should?

A

Give empiric antibiotic or antiviral therapy

Dont do a LP!!!

79
Q

Status epilepticus can induce what fluctuations in labs?

A

Brief peripheral leukocytosis

CSF pleocytois (increased WBC)

80
Q

Radiology for status epilepticus?

A

No, they cant get them while seizing

81
Q

Lorezapam and diazepam doses for status epilepticus?

A

Lorazepam 2-4mg

Diazepam 5-10mg

Equally effective

82
Q

Big difference between lorazepam and diazepam?

A

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

83
Q

DOC for status epilepticus?

A

IV lorazepam

Works better than phenytoin or phenobarbital as initial drug

84
Q

Drugs for established status epilepticus?

A

You follow the benzos with longer acting drugs

  • fosphenytoin
  • phenytoin
  • levetiracetam
  • valproate
  • lacosamide
85
Q

Loading dose for fosphenytoin?

A

20 PE/kg infused at 150 PE/min over 10-15 min

Or give it IM

86
Q

Why dont we like valproic acid?

A

It works well but it has a black box for hepatic failure and pancreatitis

Cannot be given with phenytoin

87
Q

This drug is not approved by FDA but is rapidly becoming the first line for established status epilepticus

A

What is levetiracetam?

88
Q

Current recommendations for status epilepticus refractory?

A

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

89
Q

SE refractory propofol dose?

A

2-10mg/kg/h titrated up to seizure cessation

Short 1/2 life so can be dc once they stop

90
Q

What is the risk of high dose propofol?

A

> 40mg/kg/h pts are at increased risk for hemodynamic instability

  • HOTN
  • propofol infusion syndrome
91
Q

What is midazolam and what is the dose?

A

Its a benzo

Start at 0.05 - 0.4mg/kg/h and titrate up till they quit twitching

92
Q

3rd line drugs for SE refractory?

A

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

93
Q

PVT Joker: I looked forward to meet interesting and stimulating people from a ancient culture…

A

and kill them

Senior - E Med (8 decks)

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