coma/delirium/ and epilepsies Flashcards
is delirium caused by a structural or non-structiural dysfunction?
non
is the differential for delirium a broad or narrow etiology>
broad, look for more than once cause happening at same time.
what is the delirium acronym?
drugs emotional low O2 infection retition of urine ictal states undernutrition (wernicke's) metabolic subdural cns process sensory, pain
what is the chief characteristic of delirium?
waxing and waning with agitation
iscoma caused by structural or nonstructural causes? what are the 2 exceptions
structural
drug induced and status ellipticus
review the most common causes of coma in order?
vascular trauma endocrine problem medications, drugs, ETOH Infection CNS or non--shock organ failure seizure temperatur disturbance tumor
what is the order of levels of arousal?
- alert- eyes open, maintain awake
- somnolent- sleepy, maintain awake from arousal
- obtunded- sleepy awaken from verbal but can’t stay awake
- obtunded- sleep awaken to pain, but can’t stay awake
- stupours- cannot arouse to verbal or negative stimulus- grimace
6comatose- no arousal
what is cushing’s triad?
hypertension, bradycardia and respiratory change- seen in acute ICP elevation
where is coma damage with pinpoint pupils?
pons
cheyne stokes respirations comes from damage where?
deep hemisphere or diencephalon
rhythmic hyperventialtion is from damage where?
pulmonary or metabolic
central midbrai or uppe pons
apneusis is from damage where?
dorsolateral pontine tegmentum
where is cluster breathing damage?
low pons or high medulla
where is ataxic breathing damage?
dorsomedial medulla
what is the order from best to worse in arousal of a patients movement?>
spontaneous, localizes, withrdrawals, decerebrate ro decorticate posturing, no response
how do we treat elevated ICP?
head of bed up hyperventialte hyperosmotic use (mannitol) neuroanesthetics ventricular drain (NOT LP) craniectomy
when do seizures often occur
after awakening
what can often provok generalized seizures?
sleep deprivation and alcohol
do focal seizures have an alteration of awareness?
may not
where do the majority of seizures in adults arise?
in the temporal lobe- over 65%
deep mesial structures
what is the most physiologic mimmicker of seizure?
syncope
To determine if a seizure is provoked or non-provoked, what does emergency room generally test for?
WBC, metabolic profile, drug scree
head CT if damage suspected
does normal neuroimaging exclude seizures?
no
Epileptiform discharges are often depicted as what?
sharp waves or spikes interictally
What is the sensitivity of a routine EEG?
about 30%
what increases the sensitivity of a routine EEG?
within 1st 24 hours of seizure or sleep deprived EEG
drug of choice for abscence seizures?
ethosuzimide
what anti-convulsants may worsen generalized seizures?
carbamazepine, gabapentin, pregabalin, gabatril
how many patients can control seizures with meds?
2/3
valproic acid has what 2 side effects?
weight gain and teratogen
does topiramate and zonisamide cause weight gain?
no weight loss
what drugs have fewest effects on newborn infants when mom is taking
levitiracetam and lamotrigine
if we use surgery for epilepsy, where is the surgery most likely found?
mesial temporal, brain for movement or language cannot be removed, neither can both mesial temporal lobes
how long must someone go without a seizure in order to drive?
3 months- acadamy
6months in iowa- no madatory reporting
what type of seizure do we se sudden unexpected death in epilepsy most?
generalized tonic-clonic seizures
what needs to be excluded when making a diagnosis of epilepsy?
physiologic and psychologic mimickers
patients failing 2-3 seizure meds should be?
referred to an epilepsy center
when is epilepsy surgery typically an option?
intractable focal seizures
does >10 seconds of electrographic change not associated with a clinical event constitute a seizure?
yes
what is two uprovoked seizures
epilepsy if >24hrs apart
auromatisms associated with seizures are most commonly found in what 2 places?
oral or hand
what 3 characteristics of movements are concerning for seizures?
symmetry, synchronicity, rhythmicity
what are small focal seizures that proceed or predict the onset of a patient’s typical more robust seizures?
aura- frequently autonomic or sensory in nature
somatosensory auras are frequently what lobe location?
parietal
psychlogical aura are frquently what lobe related?
frontal
deja-vu is freq what lobe associated?
temporal
what are partial seizures without alteration of conciousness?
simple partia
what are partial seizures with associated alteration of consciousness
complex partial
what has an onset 3-12 months, with trunk and extremity flexion or extension after waking?
infantile spasm
what is hypsarrhythmia?
high amplitude chaotic background on EEG associated with infantile spasm
when are febrile seizures most comon
6 mo to 5 y
a febrile seizure lasting longer than 15 min is termed?
complex- also multiple in 24 hours , small increase in future risk of epilepsy
besides ethosuximide, what can we treat absence seizures with?
lamotrigine, or valproic acid
what is a partial epilepsy characterized by facial clonic seizures and generalized TC seizures freq at night? what does EEG show
benign rolandic
bilateral independent centro temporal sharp waves with horizontal dipol
FREQUENTLY UNTREATED
when is the onset of mesial temporal lobe epilepsy
partial epilepsy usually in teens
what increases risk of mesial temporal lobe epilepsy? what is eeg?
prolonged febrile seizures
- temporal sharps and temporal intermittent rhythmic delta activity
Rx for mesial temporal seizures?
medications but frequently surgical resection
when does REM parasomnias often occur?
last third of the night whereas non-REM occur in first third
what is an acute event which frightens caretaker and caracterized by apnea, color change, limpness or rigidity and apparent choking?
Apparent life threatening events- not associated with SIDS risk, usually in young children
what is described by cyanosis, pallor, and syncope with agitation and frustration in children?
breath holding spells
what are spells of movement or alteration of consciousness without an EEG correlate?
psudoseizure- non-epileptic seizures, conversion disorder.
