Chapter 18 - Seizures

Question 1

What are three way to characterize seizures:

Answer 1

1) cause
primary or secondary (provoked)

2) effect on mentation
generalized (tonic-clonic, absence, atonic, myoclonic) or focal

3) motor activity: convulsive or non-convulsive

Question 2

What qualities define an ictal event?

Answer 2

1) abrupt onset (i.e. no aura)
2) brief duration (10-20 sec)
3) LOC (unless it’s a focal seizure)
4) purposeless activity
5) unprovoked (not provoked by emotional stimuli: exception: fever in children and substance withdrawal in adults
6) post-ictal state (acute altered state occurs post seizure except for in absence seizures )

Question 3

What age is simple febrile seizure common in pediatrics and when is it considered a red flag?

Answer 3

Common in 6 months to 5 years

red flag if febrile seizure in < 6 months

Question 4

What’s the definition of status epilepticus?

Answer 4

5 or more minutes of persistent seizures
OR
a series of recurrent seizures without return to FULL consciousness in between (i.e. no post ictal state)

Question 5

What are first line agents for status epilepticus and their doses?

Answer 5

First line: BZs

1) diazepam 0.15mg/kg IV
can be given rectally 2) Lorazepam 
0.1mg/kg IV 
preferred IV agent due to longer half life 
3) midazolam 0.2 mg/kg IV/IM/IN
-preferred for IM or buccal 

• All effective
• Give two max doses of benzos then switch to second line

-i.e.: 10 mg Midazolam x2, or 4 mg lorazepam x 2

Question 6

what are second line agents for status epilepticus and their doses:

Answer 6

-All need to be given over 10 min or so

Phenytoin -20mg/kg IV infusion
Fosphenytoin (prodrug) -20mg/kg infusion
Valproic acid: 20-40mg/kg
Propofol infusion

Question 7

What is the definition of refractory status epilepticus?

Answer 7

seizures persistently unresponsive to third line agents

Question 8

What is the treatment for refractory status epilepticus:

Answer 8

Anesthetic doses of:

• midazolam
• propofol
• isoflurane anesthesia

Need non-depolarizing NMB (i.e. ROC) and continous EEG monitoring

Question 9

List 10 differential diagnosis for seizures?

Answer 9

Epileptic causes:

1) Drugs of abuse: intoxication or withdrawal
- alcohol
- Stimulant
- LSD, PCP
- herbal products

2) Medications:
- abtibiotics
- antiarrhythmic agents
- antidepressants

3) metabolic
- hypo or hyperglycemia
- hypo or hypernatremia
- hypocalcemia
- hypomagnesemia
- hypoxia

4) infectious:
- meningitis
- cerebritis
- encephalitis
- cerebral abscess
- non CNS infection

5) structural lesions
- tumor
- Intracranial hemorrhage
- SAH
- Ischemic CVA

6) Systemic:
- eclampsia
- extreme fever
- thyrotoxicosis

NON epileptic causes:

1) Cardiac
- vasovagal
- orthostatic syncope
- cardiogenic syncope

2) Neurologic
- vertebrobasilar TIA
- migraine
- movment disorders

3) Sleep disorders
- cataplexy
- arousal disorders

4) metabolic
- hypo or hyperglycemia
- hypo or hypernatremia
- hyperthyroidism
- pheochromocytoma

5) psychogenic:
- panic attacks
- non epileptic convulsions

6) Toxic
- extrapyramidal symptoms of antipsychotics
- delirium tremons
- tetanus

Question 10

10 indications for CT imaging in new onset seizure?

Answer 10

1) first seizure
2) Acute intracranial process suspected
3) history of acute head trauma (i.e SDH)
4) history of malignancy
5) immunocompromised status
6) fever
7) persistent headache
8) history of anticoagulation
9) new focal neurological examination
10) age older than 40 without history of epilepsy
11) focal onset before generalization
12) persistently altered mental status

Question 11

What is the treatment for hypoglycemia caused seizure?

Answer 11

1) D50W for >2 year old

2) in children <2 year old, use the rule of 50
D10-25

Question 12

What is the treatment for eclampsia caused seizure?

Answer 12

consider in a seizing woman weeks GA up to 6 weeks post-partum

Mx: IV magnesium 6g over 15 min

Question 13

What is the treatment for hyponatremia/water intoxication caused seizure?

Answer 13

• typically in children, psych patients, athletes, chemo patients

Mx: with hypertonic saline

• 3% hypertonic saline: 4-6ml/kg over 1 hour (up to 100 ml)
• 5% hypertonic 50cc
• 6% saline (2 amps bicarb)

Question 14

What are the most common causes of status epilepticus?

Answer 14

1) antiepileptic drug associated: withdrawal or under dose
2) ETOH related
3) drug toxicity/post-stroke/CVA/ metabolic lytes/hypoxia/ post arrest
4) others: infection, cerebral tumour, idiopathy