Lecture 3 - Seizures 2

Question 1

Most important info obtained from patient history

Answer 1

Patient/witnesses describe events before, during and after seizure
Past medical history of patient
Medication history
Family History

Question 2

Physical exam causes of seizure

Answer 2

Head trauma
Ear/sinus infections
Alcohol/drug abuse or withdrawal
Cancer
Hyperventilation in children?

CT scan or MRI (preferred)

Question 3

EEG provides 3 types of info

Answer 3

Confirmation of abnormal electrical activity
Type of seizure disorder
Location of seizure focus

do < 48hrs post seizure, ~ 50% pts with epilepsy have normal EEG

Question 4

New onset focal epilepsy or unclassified GTC seizures use….

Answer 4

Lamotrigine = good
Lamotrigine + Gabapentin in pts > 60
Keppra n Zonisamide can be used

Question 5

New onset seizures, Focal, 1st line…

Answer 5

CBZ
GBP
LMG
LVT
OXC
ZON

Question 6

New onset seizures, Tonic Clonic, 1st line….

Answer 6

LMG
CBZ
OXC
VPA

Question 7

New onset seizures, Absence, 1st line…

Answer 7

ETH
VPA

Question 8

Refractory Seizures, focal, adjunctive options

Answer 8

CBZ
ESL
GBP
LAC
LMG
LVT
OXC
PER
PGB
TOP
ZON

Question 9

Refractory Seizures, Tonic Clonic, adjunctive options

Answer 9

CLO
LMG
LVT
TOP
VPA

Question 10

Refractory Seizures, Absence, adjunctive options

Answer 10

LMG

Question 11

Criteria for AED DC

Answer 11

Seizure free 2-5 years, mean is 3.5 yrs
Single type of partial seizure or single type of primary generalized tonic-clonic seizures
Normal neurologic examination/normal IQ
EEG normalized with treatment

Question 12

Epilepsy in elderly info

Answer 12

Txm = 1st - Lamotrigine 2nd - Gabapentin

Seizure recurrence 2 X
inc seizure morbidity
Prolonged post-octal state

Question 13

Epilepsy in Pediatrics Tonic clonic

Answer 13

Topiramate
Eslicarbazepine
Lacosamide

Question 14

Epilepsy in Pediatrics Absence seizures

Answer 14

Ethosuximide
Valproate
Lamotrigine

Question 15

General Txm of Seizures

Answer 15

1. remove known causes
2. educate patient, risk for falls etc
3. start with 1st line as monotherapy, add others as needed..try to wean once controlled

Question 16

Status Epilepticus info

Answer 16

Seizure lasting > 5min or > 2 seizures without return to baseline between them

Medical emergency, many pts cant breathe during it and can result in brain damage

High mortality

Question 17

Status Epilepticus Diazepam

Answer 17

IV: 0.15-0.2 mg/kg (Max 10mg), may repeat X 1

PR: 0.2-0.5mg/kg (max 20mg) X 1

Into brain quickly, but also out fast.
highly lipophilic

Question 18

Status Epilepticus Lorazepam

Answer 18

0.1mg/kg (max 4mg) IV may repeat X 1

Longer in brain than diazepam

Question 19

Status Epilepticus Midazolam

Answer 19

Pt > 40k = 10mg IM X 1
pt 13-40kg = 5mg IM X 1

Intranasal or buccal forms available

Question 20

Status Epilepticus Fosphenytoin

Answer 20

20mg/kg IV at 150mg/min (1500mg max)
May take 20min for effect, but longer lasting

Question 21

Status Epilepticus Phenobarbital

Answer 21

15mg/kg IV X 1 t 50-75mg/min

Longer effect, sedation may confound mental status assessment

Question 22

Status Epilepticus Levetiracetam

Answer 22

60mg/kg IV X 1 (4500mg max)

Question 23

Status Epilepticus Algorithm

Answer 23

0-5 min = stabilization phase, maybe EKG, BG lvls

5-20min = initiation therapy…start with benzo (Diaz, Lorazepam, Midaz) move to other meds if dont have those

still seizing after 20-40min = add other meds (fosphenytoin, Keppra, Valproic acid)
still seizing after 40-60min = use anesthetic dose of thiopental, midaz, pentobarbital,propofol