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Acute Care I - Spring 2017 > Module 9: Seizure & Status Epilepticus > Flashcards

Module 9: Seizure & Status Epilepticus Flashcards

1
Q

are seizures more common in men or women?

A

more common in men

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2
Q

what age group is more common for seizures?

A

more common in children. increased rate in adults > 55 years old

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3
Q

what ethnicity has greater risk for seizures

A

hispanics > non-hispanics.

caucasians > african americans

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4
Q

definition of seizure

A

abnormal, paroxysmal, excessive discharge of CNS neurons; occurs in 5-10% of the population; clinical manifestations can range from dramatic to subtle

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5
Q

definition of epilepsy

A

recurrent seizures due to an underlying cause 0.5-1%

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6
Q

definition of status epilepticus

A

continuous tonic-clonic seizure > 30 min or repeated seizures with no resolution of postictal periods.

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7
Q

definition of generalized seizures

A

-diffuse brain involvement

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8
Q

definition of tonic clonic generalized seizures

A

tonic phase with contraction of muscles causing expiratory moan, cyanosis, pooling of secretions, tongue biting lasting 10-20 seconds.

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9
Q

absence generalized seizures

A

transient lapse of consciouss w/o loss of postural tone

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10
Q

myoclonic generalized seizures

A

sudden, brief contraction

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11
Q

partial seizures

A

involves discrete areas implying a focal or structural lesion

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12
Q

simple partial seizures

A

without impairment of conscioiusness, may be motor, sensory, or autonomic

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13
Q

complex partial seizures

A

with impairment of consciousness +/- automatisms or psychogenic features

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14
Q

partial w/ secondary generalized

A

starts focal then becomes diffuse

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15
Q

etiology of seizures

A

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)

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16
Q

clinical manifestations - aura

A

seconds to minutes; premotions consisting of abnormal smells/tastes, unusual behavior, oral or appendicular automatisms

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17
Q

clinical manifestations - ictal period

A

seconds to minutes, tonic and/or clonic movement of head, eyes, trunk or extremities

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18
Q

clinical manifestations - postictal period

A

minutes to hours; slowly resolving period of confusion, disorientation and lethargy. may be accompanied by focal neurological deficits (Todd’s paralysis)

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19
Q

clinical evaluation of seizures

A

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

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20
Q

HPI should include

A

recent illnesses/fevers, head trauma

-medications, alcohol & illicit drug use

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21
Q

PMH should include?

A

prior seizures, Family history of seizures, prior meningitis/encephalitis, prior stroke or head trauma

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22
Q

general physical exam should include?

A

skin (looking for neuroectodermal disorders - neurofibromatosis, tuberous sclerosis) that are associated w/ seizures

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23
Q

neurological exam should include?

A

looking for focal abnormalities, underlying structural abnormality

24
Q

what is on the differential diagnosis for seizure?

A

syncope - but lacks true aura, motor manifestations < 30 seconds and w/o postictal disorientation, muscle soreness or sleepiness.

skin pallor and clamminess support syncope

25
Q

pseudo-seizure vs seizure

A

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

26
Q

other differential diagnosis

A

metabolic disorders (ETOH blackouts, hypoglycemia), migraines, TIAs, narcolepsy, non epileptic myoclonus

27
Q

what diagnostic studies to get

A

full electrolytes, BUN/Cr, glucose, LFTs, tox screen, medication levels.

28
Q

what can EEG show you?

A

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

29
Q

what does MRI help with for seizures?

A

r/o structural abnormalities.

30
Q

what does Lumbar puncture help w/ for seizures

A

after r/o space occupying lesion and if suspect meningitis or encephalitis and in all HIV + patients

31
Q

how do you treat seizure

A

treat underlying causes, including CNS infections, intoxication, or withdrawal

32
Q

when do you use AED (anti-epiletic drugs)? therapy

A

usually reserved for pts w/ underlying structural abnormality or an idiopathic seizure +

  1. status epileptics on presentation
  2. focal neurologic exam
  3. postitctal Todd’s paralysis
  4. abnormal EEG
33
Q

what do you use to treat generalized tonic-clonic seizures

A

valproic acid, phenytoin, topiramate, lamotrigine

34
Q

how to treat partial w or w/o secondary generalization

A

carbamazepine, oxcarbazepine, lamotrigine, phenytoin, valproic acid

35
Q

how to treat absence seizures

A

ethosuximide, valproic acid

36
Q

what are secondary agents for seizure treatment?

A

leviteracitam, gabapentin, clonazepam, phenobarbital

37
Q

what are some considerations for seizure meds?

A
  • introduce gradually while monitoring carefully

- may consider withdrawal if seizure free (typically for at least 1 year) and normal EEG

38
Q

state law re: driving?

A

individual state laws mandate seizure free duration before being allowed to drive

39
Q

what is status epilepticus

A

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

40
Q

what is non-convulsive stats epilepticus?

A

alteration of awareness ranging from confusion to coma w/o motor manifestations. only way to diagnose is w/ EEG

41
Q

what is phase 1 of status epileptics?

A
  • 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
42
Q

what is Level A recommendations for medication for phase 1 status epilepticus?

A

5 mg IM Midazolam, 5 mg IV Diazepam, 4 mg IV Lorazepam

43
Q

what is considerations for administering Level A for phase 1 of status epilepticus?

A
  • 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
44
Q

what is Level B recommendations for phase 1 status epileticus?

A

PR Diazepam, intranasal/buccal Midazolam. this for pre-hospital setting where first line is not available

45
Q

what is status epilepticus phase 2?

A

-seizure duration 20-40 minutes when response or lack of response to second line therapy apparent

46
Q

medication recommendation for phase 2 status epileticus

A

Level B: valproic acid, phenobarbital - given adverse events, if none of the other three are available

Level U:

47
Q

what is status epilepticus phase 3

A

when seizure duration reaches 40 minutes - there is no clear evidence to guide therapy

48
Q

what should you give for status epilepticus

A

may repeat second line therapy OR anesthetic doses of thiopental, midazolam, propofol, pentobarbital
-if anesthetic doses are administered, must place patient on continuous EEG

49
Q

what to do for refractory status epilepticus

A
  • 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
50
Q

when does propofol infusion syndrome happen?

A

generally above the recommened dose,

-propofol labs: LFTs, lactate

51
Q

data on how to treat status epilepticus?

A

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
52
Q

when can you withdrawal continuous infusion?

A

after seizure control maintained for 24-48 hours.

53
Q

is there a defined time for weaning for refractory status epilepticus trials are considered futile?

A

no - no defined duration of electrographic seizure control or number of trials of seizure control after which care is considered futile

54
Q

how do you guide continuous to maintenance therapy?

A

there is no date for guiding transitioning from continual to maintenance thearpy

55
Q

what are some alternative therapies?

A
  • 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
56
Q

what are independent predictors of remission

A
  • 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.

Acute Care I - Spring 2017 (10 decks)

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