Module 9: Seizure & Status Epilepticus Flashcards
are seizures more common in men or women?
more common in men
what age group is more common for seizures?
more common in children. increased rate in adults > 55 years old
what ethnicity has greater risk for seizures
hispanics > non-hispanics.
caucasians > african americans
definition of seizure
abnormal, paroxysmal, excessive discharge of CNS neurons; occurs in 5-10% of the population; clinical manifestations can range from dramatic to subtle
definition of epilepsy
recurrent seizures due to an underlying cause 0.5-1%
definition of status epilepticus
continuous tonic-clonic seizure > 30 min or repeated seizures with no resolution of postictal periods.
definition of generalized seizures
-diffuse brain involvement
definition of tonic clonic generalized seizures
tonic phase with contraction of muscles causing expiratory moan, cyanosis, pooling of secretions, tongue biting lasting 10-20 seconds.
absence generalized seizures
transient lapse of consciouss w/o loss of postural tone
myoclonic generalized seizures
sudden, brief contraction
partial seizures
involves discrete areas implying a focal or structural lesion
simple partial seizures
without impairment of conscioiusness, may be motor, sensory, or autonomic
complex partial seizures
with impairment of consciousness +/- automatisms or psychogenic features
partial w/ secondary generalized
starts focal then becomes diffuse
etiology of seizures
A: alcohol withdrawal, illicit drugs, meds (beta-lactams, meperidine, anti-depressants, clozapine)
B: brain tumor or penetrating trauma
C: cerebrovascular disease including subdural hematomas, hypertensive encephalopathy, hemorrhagic strokes
D: degenerative disorders of the CNS (Alzheimer’s)
E: electrolyte (hyponatermia) & other metabolic (uremia, liver failure, hypoglycemia)
clinical manifestations - aura
seconds to minutes; premotions consisting of abnormal smells/tastes, unusual behavior, oral or appendicular automatisms
clinical manifestations - ictal period
seconds to minutes, tonic and/or clonic movement of head, eyes, trunk or extremities
clinical manifestations - postictal period
minutes to hours; slowly resolving period of confusion, disorientation and lethargy. may be accompanied by focal neurological deficits (Todd’s paralysis)
clinical evaluation of seizures
patient usually w/o recollection of events. if witness presents must ask for details:
A. unusual behavior before seizure (ie aura)
B. type and pattern of movement, including head turning & eye deviation (gaze preference away from seizure focus)
C loss of responsiveness
HPI should include
recent illnesses/fevers, head trauma
-medications, alcohol & illicit drug use
PMH should include?
prior seizures, Family history of seizures, prior meningitis/encephalitis, prior stroke or head trauma
general physical exam should include?
skin (looking for neuroectodermal disorders - neurofibromatosis, tuberous sclerosis) that are associated w/ seizures
neurological exam should include?
looking for focal abnormalities, underlying structural abnormality
what is on the differential diagnosis for seizure?
syncope - but lacks true aura, motor manifestations < 30 seconds and w/o postictal disorientation, muscle soreness or sleepiness.
skin pallor and clamminess support syncope
pseudo-seizure vs seizure
may see side to side head turning, asymmetric large amplitude limb movements, diffuse twitching w/o LOC and crying/talking during event.
-commonly pseudo-seizure is associated w/ psychiatric history
other differential diagnosis
metabolic disorders (ETOH blackouts, hypoglycemia), migraines, TIAs, narcolepsy, non epileptic myoclonus
what diagnostic studies to get
full electrolytes, BUN/Cr, glucose, LFTs, tox screen, medication levels.
what can EEG show you?
frequent seizures: can confirm by demonstrating repetitive rhythmic activity. Generalized seizures will always have abnormal EEG, however partial seizures may not
-infrequent seizures: may show interictal epileptiform activity such as spikes or sharp waves, but such patterns seen in up to 2% of normal population
sleep deprivation increases diagnostic yield of EEG. video monitoring may help w/ psychogenic seizures
what does MRI help with for seizures?
r/o structural abnormalities.
what does Lumbar puncture help w/ for seizures
after r/o space occupying lesion and if suspect meningitis or encephalitis and in all HIV + patients
how do you treat seizure
treat underlying causes, including CNS infections, intoxication, or withdrawal
when do you use AED (anti-epiletic drugs)? therapy
usually reserved for pts w/ underlying structural abnormality or an idiopathic seizure +
- status epileptics on presentation
- focal neurologic exam
- postitctal Todd’s paralysis
- abnormal EEG
what do you use to treat generalized tonic-clonic seizures
valproic acid, phenytoin, topiramate, lamotrigine
how to treat partial w or w/o secondary generalization
carbamazepine, oxcarbazepine, lamotrigine, phenytoin, valproic acid
how to treat absence seizures
ethosuximide, valproic acid
what are secondary agents for seizure treatment?
leviteracitam, gabapentin, clonazepam, phenobarbital
what are some considerations for seizure meds?
- introduce gradually while monitoring carefully
- may consider withdrawal if seizure free (typically for at least 1 year) and normal EEG
state law re: driving?
individual state laws mandate seizure free duration before being allowed to drive
what is status epilepticus
continuos tonic-clonic seizure >30 minutes or repeated seizures such that there is no resolution of postictal periods. complications include neuronal death, rhabdomyolysis and lactic acidosis
what is non-convulsive stats epilepticus?
alteration of awareness ranging from confusion to coma w/o motor manifestations. only way to diagnose is w/ EEG
what is phase 1 of status epileptics?
- 0 to 5 minutes
- standard initial first aid –> airway, positioning, IV access
- initial therapy phase should begin when seizure duration has reached 5 minutes and conclude by 20 minute mark by either response or lack of response to thearpy
what is Level A recommendations for medication for phase 1 status epilepticus?
5 mg IM Midazolam, 5 mg IV Diazepam, 4 mg IV Lorazepam
what is considerations for administering Level A for phase 1 of status epilepticus?
- IV phenobarbital is well tolerated as initial therapy, but has slower administration, it is alternative, rather than first line
- should be given in single full doses
- IV Lorazepam & Diazepam may be repeated once at full dose
what is Level B recommendations for phase 1 status epileticus?
PR Diazepam, intranasal/buccal Midazolam. this for pre-hospital setting where first line is not available
what is status epilepticus phase 2?
-seizure duration 20-40 minutes when response or lack of response to second line therapy apparent
medication recommendation for phase 2 status epileticus
Level B: valproic acid, phenobarbital - given adverse events, if none of the other three are available
Level U:
what is status epilepticus phase 3
when seizure duration reaches 40 minutes - there is no clear evidence to guide therapy
what should you give for status epilepticus
may repeat second line therapy OR anesthetic doses of thiopental, midazolam, propofol, pentobarbital
-if anesthetic doses are administered, must place patient on continuous EEG
what to do for refractory status epilepticus
- it is failed attempts to control with first and second line therapy
- may consider to administer repeat boluses of chosen AED
- continuous IV administration of midazolam, propofol, pentobarbital or less often thiopental
when does propofol infusion syndrome happen?
generally above the recommened dose,
-propofol labs: LFTs, lactate
data on how to treat status epilepticus?
no data to support a standardized regimen for the intensity/duration of treatment.
- treatment duration is usually dictated by cEEG monitoring and cessation of electrographic seizures or burst suppression
- recommended that cEEG findings rather than drug levels guide therapy
when can you withdrawal continuous infusion?
after seizure control maintained for 24-48 hours.
is there a defined time for weaning for refractory status epilepticus trials are considered futile?
no - no defined duration of electrographic seizure control or number of trials of seizure control after which care is considered futile
how do you guide continuous to maintenance therapy?
there is no date for guiding transitioning from continual to maintenance thearpy
what are some alternative therapies?
- just case reports, no RCT/compelling evidence to support
- Ketamine, corticosteroids, inhaled anesthetics, immunomodulation (IVIG)
- vagus nerve stimulator, hypothermia, ketogenic diet, electroconvulsive therapy, trans cranial magnetic stimulation, surgical management
what are independent predictors of remission
- absence of organic brain damage
- low intensity seizure propensity
- good early effect of drug therapy
- long term outcome often predictable by observation of the early outcome of seizures.
