Neuro Emergency- Seizures

Question 1

What is the definition of a seizure?

Answer 1

A seizure is a transient occurence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. It is the result of chaotic electrical impulses in the brain

Question 2

What is the definition of ‘Epilepsy’?

Answer 2

Epilepsy is a neurological disorder in which brain activity becomes abnormal, causing recurrent and unprovoked seizures. Often diagnosed following 2 or more unprovoked seizures which have been caused by abnormal excessive or synchronous neuronal activity in the brain

Question 3

Explain what ‘Status Epilepticus’ means. Provide the epidemiological definition and then clinical (operational) definition

Answer 3

Status Epilepticus is a life threatening emergency which is classified as:
Clinical/Operational Criteria= Seizure lasts >5min, or, 2 or more seizures that occur in the absence of a complete recovery of consciousness (GCS15) between
Epidemiological Criteria= Seizure lasts >30min, or, a series of epileptic seizures in a 30min period during which function is not regained between ictal events

Question 4

What is ‘Refractory Status Epilepticus’?

Answer 4

Refractory Status Epilepticus= when status epilepticus continues despite administration of benzodiazepines

Question 5

If a patients motor movement during a seizure is described as ‘tonus’ or ‘tonic’, what does this mean?

Answer 5

Tonus/Tonic= musclular contraction
:D Memory hack- ‘tonus is tight, clonus is clicking’

Question 6

If a patients motor movement during a seizure is described as ‘conlus’ or ‘clonic’, what does this mean?

Answer 6

Clonus/Clonic= Muscular jerking
:D Memory hack- ‘tonus is tight, clonus is clicking’

Question 7

If a patients motor movement during a seizure is described as ‘atonic’, what does this mean?

Answer 7

Atonic= muscular flaccidity

Question 8

What does the concept ‘Jacksonian March’ refer to in relation to seizures?

Answer 8

Jacksonian March= Used to describe the progression of seizure activity in a focal onset seizure with maintained awareness. A ‘Jacksonian’ seizure will usually start from the distal part of the limb before ‘marching’ (progressing) to the entire hand/arm/foot/leg

Question 9

What does ‘Todd’s Paresis/Palsy’ refer to in relation to seizures?

Answer 9

Todds Paresis/Palsy refers to focal (unilateral) muscular weakness following a seizure. It can also affect eye gaze, speech and vision. It can mimic a stroke, however this can often be ruled out as it occurs following a seizure

Question 10

What are the 4 Stages of seizures?

Answer 10

Stage 1= Prodromus (period between 1st symptom & full development of seizure. Can be mins/hrs/days
Stage 2= Aura (initial alterations in perception- eg. emotion, hearing, smell, taste, vision. Usually secs/mins before seizure)
Stage 3= Ictus (the seizure itself)
Stage 4= Post-ictal (state of confusion following a seizure. Lasts min-hrs after seizure, but is not always present)

Question 11

What are some key signs and symptoms of the ‘Post-ictal’ stage?

Answer 11

Common signs/symptoms during the Post-ictal phase:
1. Neuro deficits- Confusion (from hypoxia), disorientation, anxiety
2. Hyperglycaemia, or Hypoglycaemia
3. Headache/migraine- can cause nausea & vomiting
4. Incontinence (bladder & bowel) as pelvic muscles tense- pressure put on bladder/bowel, loss of control

Question 12

What are the 3 overarching classifications of seizures?

Answer 12

Seizure Types:
1. Focal Onset (unilateral)
2. Generalised Onset (bilateral)
3. Unknown Onset

Question 13

What are the different ways of describing: Focal Onset Seizures? Describe the signs & symptoms that are common during each type of focal seizure

Answer 13

Focal Onset Seizure:
1a- With awareness- during seizure pt knows what is happening, is able to respond, and has memory of the seizure
1b- With impaired awareness- loss of knowledge of what is happening, inability to respond, confusion, impaired memory for any portion of the seizure
2a- Motor onset- unilateral muscular movements (tonic, clonic, tonic-clonic)
2b- Non-motor onset- main symptoms are not muscular in nature but can include changes to sensory input, autonomic function, emotions, or cognition

Question 14

What are the different ways of describing: Generalised Onset Seizures? Describe what you are likely to see with each type

Answer 14

Generalised Onset Seizure:
a) With motor activity- this is a tonic/clonic seizure where there are bilateral movements of the arms & legs (includes tonic phase- muscle contraction, and clonic phase- muscle jerking)
b) Without motor activity- this is an absence seizure. The pt will remain conscious but awareness will be lost. Often starts/stops abruptly, and involves less complex automatisms (lip smacking, hand movements)

Question 15

What type of medication is Midazolam, and how does it help to stop seizures?

Answer 15

Midazolam is a short acting benzodiazepine. By rapidly enhancing the effect of the neurotransmitter GABA (gamma aminobutyric acid) and causing central nervous system depression- this results in sedation, anxiolytic effects, anti convulsant effects by relaxing of muscles, as well as amnesic effects

Question 16

What are some key considerations for paramedics for management of an active seizure?

Answer 16

Danger- remove/clear space around patient, protect head with towel/pillow, do not restrain movement
Airway- use NPA to ensure patency
Breathing- put hudson/therapy mask on patient at 8L
Correct underlying cause if known (eg. hypoglycaemia, hypoxia)
Administer midazolam

Question 17

Why do some patients end up having hyperglycaemia following a seizure?

Answer 17

Hyperglycaemia following a seizure occurs because during the seizure, glycogen stores are converted to glucose to ensure there is enough glucose for the increased oxygen demands. If its not all used during the seizure, this results in hyperglycaemia after it

Question 18

During a seizure, cerebral oxygen use increases by _%

Answer 18

During a seizure, cerebral oxygen use increases by 60%

Question 19

During a seizure, cerebral blood flow increases by _%

Answer 19

During a seizure, cerebral blood flow increases by 250%

Question 20

During a seizure, maintenance of seizure activity requires a __% increase in the concentration of ATP in the brain

Answer 20

During a seizure, maintenance of seizure activity requires a 250% increase in the concentration of ATP in the brain

Question 21

What are some conditions which can mimic a seizure? (conditions that may look like a seizure, but aren’t)

Answer 21

Seizure Mimics- Conditions that may look like a seizure, but aren’t:
a) Syncope with twitching
b) Sleep disorders such as Narcolepsy (instantaneously fall asleep)
c) Tardive Dyskinesia (a type of extra pyramidal reaction which causes involuntary movements of the face including tongue, lip, face)
d) Cataplexy (sudden muscle weakness following strong emotions)
e) Psychiatric conditions (panic attacks, dissociation)

Question 22

What are some conditions that can provoke/precipitate seizures other than an epileptic disorder?

Answer 22

Recognisable causes of seizures:
a) Metabolic conditions (hypoglycaemia, hyperglycaemia)
b) Illicit drugs/toxins/OD (psychostimulants, alcohol withdrawal, serotonin syndrome, overdoses)
c) Meningitis (inflammation of fluid & membranes in brain/spinal cord)
d) Cerebral events (TBI, strokes, tumours, encephalitis)
e) Hypoxia
f) Hyperthermia (febrile convulsions)
g) Psychiatric conditions (FND, PNES)

Question 23

What is a medical condition that may mimic a seizure aura (stage 2 of a seizure)?

Answer 23

Seizure auras (alterations in perceptions- emotions, hearing, smell, taste, vision)
can be mimicked by:
MIGRAINES
They can cause photosensitivity, odd tastes, ringing in ears, noise sensitivity