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Neurology 2 > Clin Med - Seizures > Flashcards

Clin Med - Seizures Flashcards

1
Q

define status epilepticus

A

-30 min of continuous seizure activity
or
-multiple seizure w/o return to neurologic baseline
-it can look like pt came out of full seizure activity but they never quite do

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2
Q

generalized convulsive status epilepticus is ?

A

-5 min of pronounced motor activity w/ tonic contractures followed by clonic jerking

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3
Q

generalized nonconvulsive status epilepticus is ?

A
  • typically happens after convulsive status

- more subtle jerks of the face, eyes and extremities with less intense motor activity

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4
Q

how to determine convulsive from non convulsive on EEG

A

you can’t, they’re often identical

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5
Q

convulsive status epilepticus danger

A
  • more rapidly damaging

- should be aggressively treated

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6
Q

nonconvulsive status epilepticus

A
  • harder to diagnose
  • could be finding a pt w/ altered mental status that is worse than expected for his/her underlying condition
  • should raise concern
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7
Q

pathophys of status

A
  • first and rapid changed d/t protein phosphrorylation
  • opening and closing of ion channels and release of NTs and modulators
  • AEDs work at this level
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8
Q

3 things excitation can come from in status

A
  1. established epileptogenic circuit from preexisting epilepsy
  2. excitation from the region surrounding a structural lesion
  3. diffuse excitation from a toxic or metabolic state
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9
Q

what process during status is described as angina of the brain?

A
  • accumulation of extracellular K+
  • increases susceptibility of nuerons to repeated and continuous depolarizations
  • causes oscillating paroxysms b/w cortex and subcortical areas
  • this process increases 2-3 fold in high O2 need – “angina of brain”
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10
Q

general overview of guidelines for tx of status

A
  • have a plan
  • start IV
  • therapeutic endpoint = cessation of seizure
  • be prepared to ventilate
  • use adequate doses
  • less risk of giving too much than the risk of under treating
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11
Q

important of timing in the tx of status

A
  • early!!
  • tx becomes less effective the longer it lasts
  • time to tx is more important than the sequence of meds
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12
Q

drugs to avoid in tx of status

A
  • narcotics
  • phenothiazines (antiemetic)
  • paralyzing agents (except briefly during intubation)
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13
Q

where/when should tx for status be started?

A

tx is most effective when started in the field

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14
Q

first line meds for tx of status

A
  • lorazepam
  • midazolam
  • diazepam
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15
Q

second line meds for tx of status

A
  • phenytoin
  • fosphenytoin
  • valproate
  • levetiracetam
  • lacosamide
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16
Q

third line meds for tx of status

A
  • propofol
  • midazolam
  • pentobarbital
  • ketamine
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17
Q

more recent studies show better efficacy for what tx vs lorazepam?

A

IM midazolam

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18
Q

lorazepam

  • dose
  • onset
  • duration
A
  • 0.1 mg/kg at rate of 2mg/min
  • onset: 6-10 min
  • duration: 12-24 hrs
  • refractoriness often occurs after 1-2 days
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19
Q

diazepam (valium)

  • onset
  • duration
  • side effects
A
  • onset: 1-3 mins
  • duration: 15-30 mins
  • CNS depressant: decreased BP and respirations
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20
Q

phenytoin

  • onset
  • rate
  • duration
  • side effects
A
  • onset: 10-30 min
  • *don’t exceed a rate of 50mg/min to reduce risk of cardio events
  • duration: 24-36 hrs
  • may decrease bp and HR

*don’t use unless no other option

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21
Q

fosphenytoin

A
  • can be given at faster rate

- a prodrug converted to phenytoin in the liver before exerting effect

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22
Q

levetiracetam (keppra)

A
  • no hepatotoxicity, low does in renal failure
  • great for pt in ER being noncompliant w/ breakthrough seizure
  • SAFE!
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23
Q

valproic acid (depacon)

  • dose
  • effectiveness
A
  • 25mg/kg followed by 500mg IV q 6 hrs

- effectiveness depends on early admin

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24
Q

when all else fails… what med?

A

midazalam (versed)

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25
Q

midazalam dose

A
  • 0.2 mg/kg initial bolus w/ maintenance of 0.1-2mg/kg/h
  • need EEG monitoring
  • best to avoid if possible b/c more likely to cause hypotension and pancreatitis
26
Q

what specific condition is phenobarbital good for?

A

-ETOH withdrawal seizures

27
Q

in status, if you exhaust all the option and pt is still in status, what is the next step?

A

-put them in deep barbiturate coma (phenobarbital)

28
Q

phenobarbital

A
  • last resort tx
  • associated w/ danger of severe hypotension
  • very long half life so could take a long time to wake up pt
29
Q

timeline of status

A
  • ambulence picks up pt (20 min)
  • it’s refractory if > 1 hr and has high mortality rate
  • gets to ER (20 min)
  • you make diagnosis (5 min)
  • start IV
  • give lorazepam
  • intubate
  • give 2nd line drugs
  • send pt to ICU/transfer out
30
Q

what is the single best prognostic indicator of a good outcome for status:

A
  • how many minutes pass b/w onset of status and giving the pt 0.1 mg/kg of lorazepam
  • DO NOT DELAY!
31
Q

categories of epilepsy

A
  1. focal
    - simple
    - complex
  2. generalized
32
Q

focal epilepsy

A

involving brain networks confined to 1 hemisphere

33
Q

simple focal

A
  • don’t impair consciousness
  • consist of autonomic, cognitive, emotional, somatosensory, visual or involuntary motor activity
  • equivalent to the old term aura
34
Q

complex focal

A
  • impaired or altered conciousness - can cause behavioral arrest
  • staring, oral/manual limb automatisms like chewing, lip smacking, aimless fumbling hand movements
  • amnesia most likely to occur
35
Q

what is the term for when a focal seizure becomes generalized?

A

secondary generalized

36
Q

generalized

A

beginning in b/l distributed networks synchronously in both hemispheres from onset

37
Q

chacteristics of a frontal seizure

A
  • focal clonic motor

- hypermotor behavior

38
Q

characteristics of a temporal seizure

A
  • autonomic
  • dysmnesic
  • deja vu
  • jamais vu
  • gustatory
  • olfactory
  • auditory
  • complex visual
  • dysphasia
39
Q

characteristics of a parietal seizure

A

somatosensory

40
Q

characteristics of an occipital seizure (rare)

A

simple visual

41
Q

absence seizure

A

staring w/ unresponsiveness w/o aura or postictal state

42
Q

atonic/astatic seizure

A

loss of muscle tone and falling

43
Q

tonic seizure

A

sustained abnormal posturing of the extremities (<15 sec) w/ or w/o vocalization, apnea and falling

44
Q

myoclonic seizure

A

-sudden brief jerks or twitching or limp or axial muscles, consciousness usually preserved

45
Q

clonic seizure

A

repetitive jerking movements

46
Q

tonic clonic seizure

A
  • intial tonic posturing phase followed by several mins of postictal stupor, confusion and language or motor dysfunction (Todd paralysis)
  • loss of bladder or bowel continence and tongue lac from biting
47
Q

chart on seizure types

A

review slide 37

48
Q

EEG

A
  • can be done on pt awake or asleep, outpatient or inpatient
  • uses activating procedures
  • may need repetitive EEGs
49
Q

how do epileptiform abnormalities normally appear on EEG?

A
  • spikes
  • sharp waves
  • spike-wave discharges distinct from the normal background activity and indicate an increased seizure activity
50
Q

high predicitor of recurrent seizures on EEG

A

abnormal EEG after first time seizure

51
Q

what are causes that could cause epileptiform abnormalities on EEG other than seizure

A
  • occipital spikes if blind
  • generalized spikes in relatives of pts w/ genetic epilepsy
  • interictal epileptiform discharges d/t meds like buproprion/tramadol or pts w/ renal failure or acute encephalopathy
52
Q

examples of provoked seizures

A
  • alcohol withdrawal
  • severe hypotension
  • severe hypoglycemia
  • cardiac arrhythmia w/ brief syncope
  • drugs
  • extreme sleep deprivation
  • meds
53
Q

what meds can provoke a seizure

A
  • tramadol
  • imipenem
  • theophylline
  • buproprion
54
Q

a provoked seizure is often what kind?

A

generalized convulsive - not focal

55
Q

who are the pts that will most likely end up taking AEDs

A
  • hx of remote seizures
  • > 60 yo, new unprovoked
  • prior brain lesion or insult
  • EEG abnormality
  • significant brain-imaging abnormality
  • nocturnal seizure
  • sx of focal seizure
  • focal seizure w/ secondary generalization
56
Q

what seizure type doesn’t follow the general guidelines?

A

juvenile myoclonic epilepsy

57
Q

juvenile myoclonic epilepsy

A
  • MC genetic generalized epilepsy

- present w/ generalized tonic-clonic seizure, often provoked

58
Q

common pt hx in juvenile myoclonic epilepsy

A
  • hx of early morning myoclonic jerks triggered by sleep deprivation
  • pt will attribute to nervousness or clumsiness
  • so they think the tonic-clonic presentation is the first seizure
59
Q

tx of juvenile myoclonic epilepsy

A
  • valproic acid but high ADRs
  • lamotrigine is a good 2nd choice
  • avoid provoking factors
60
Q

epilepsy drugs???

A

she talked about a lot of them but…. focus on letassys????

Neurology 2 (21 decks)

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