seizure Flashcards
epilepsy
- recurrent (>2) unprovoked seizures
- usually sz stops spontaneously
classification of seizures
- generalized
- partial/ focal -> simple vs. complex
generalized seizure
- hits both hemispheres of brain
- LOC
examples of generalized sz
- tonic clonic
- absense
- myoclonic
- atonic
- tonic
- clonic
partial simple sz
- only impacts one part of the brain, stays local
- no LOC
- typical, reproducible patterns
- lasts seconds- minutes
partial complex sz
- starts as a localized sz but then generalizes
- LOC/ altered consciousness for 60-90 seconds
- behavioral arrest -> staring, automatisms -> post ictal confusion
- often have an aura
potential phases of sz
- prodrome
- preictal/ aura
- ictal
- post ictal
prodromal phase of sz
- premonition prior to sz
- “emotional change”
- mood change
- sleep disturbance
- lightheadedness
- anxiety
- can occur hours- days before sz
aura or preictal phase of sz
- occurs prior to sz
- sensory or experiential warning
- visual
- olfactory
- auditory
- psychic
- tactile
- can be hours- days before
postictal phases
- after the sz
- simple partial may not have postictal phase
- memory loss
- confusion/ agitation
- difficulty talking
- exhaustion, weakness
- HA
- nausea
things that may provoke a sz
- metabolic/ electrolyte abnormalities
- stimulants, OD
- sedative or ethanol withdrawal
- sleep deprivation
- AED med reduction or inadequate tx*
- fever in peds
- infx
- CVA, ICH
- tumor
- cardiac arrhythmias
what is a PE finding that suggests seizure
- lateral tongue lacerations
what are seizure mimics
- syncope*
- narcolepsy
- movement disorders
- PNES
common parts of work up for first time seizure
- CMC, BMP, HCG, glucose
- lactate, prolactin
- blood and urine tox
- LP if febrile, immunocomp, and CT already done
- EKG
- EEG if pt is not improving
- CT or MRI
dx of seizure
- history*
- EEG/ video EEG
counseling for new dx of seizure
- avoid precipitants
- avoid driving for at least 6 mo and until EEG/ imaging
- caution with bathing, swimming, working at heights
partial motor seizures
- jerky, rhythmic movement
- remain restricted to one body segment or spread by jacksonian march
- 25% of childhood epilepsy and remits by 16
- no specific DOC
- surgery for medically refractory sz
jacksonian march
- abnormal electrical activity that travels up the homunculus
- thumbs -> hands -> arms
sensory/ experiential partial seizures
- positive sensations
- negative sensations
- deja vu or jamais vu
- affective fear, depression, joy, anger
- hallucination: visual or auditory
- illusory: altered perception
autonomic partial sz
- less common
- abdominal, cardiac, respiratory, urogenital sx
what is an automatism
- non-purposeful, stereotyped and repetitive behavior
- chewing, lip smacking
fumbling with hands - picking
- mumbling
frontal lobe sz
- complex partial sz
- bizzare motor behavior like bicycling
temporal lobe sz
- may be just an aura and/or complex partial sz
absense sz
- brief generalized sz
- impaired consciousness
- no aura, post ictal phase, loss of postural tone
- staring episodes, confused, detached, withdrawn
- aka petit mal
- no or few automatisms
who do absence sz usually affect
- children/ adolescence
- may continue on into adulthood but usu resolves
- suspect in child with sudden drop in school performance
triggers of absence sz
- hyperventilation
- phonic stimulations
- bright lights
tx of absence sz
- depends on if other sz present
- only absence: ethosuximide
- others: valproic acid, topiramate, lamotrigine
myoclonic sz
- brief arrhythmic jerking movement
- generalized sz
- less than 1 sec, often cluster
tonic sz
- generalized sz
- sudden onset
- ext or flex of head, neck trunk and/or extremities
- typically occurs in relation to drowsiness
clonic sz
- rhythmic jerking motor mvmt
- +/- LOC
- typically involves UE and LE at same time
- rare and typically in babies
- generalized sz
atonic sz
- “drop attack”
- generalized sz
- brief loss of postural tone
- multiple falls/ injuries- often wear helmets
- < 15 seconds
- congenital, do not grow out of these
tx options for generalized sz
- valproic acid
- lamotrigine
- topiramate
- levetiracetam
- try mono, max of monotx before adding on second agent
tonic clonic sz
- aka grand mal sz
- several motor behaviors lasting 1-2 minutes
- prodromal ictal cry
- tonic pase
- clonic phase
- post ictal phase
- no aura, may have prodrome
tonic phase of tonic clonic sz
- 10-20 sec
- ext of extremities
- flex of neck and trunk
- apnea -> cyanosis
clonic phase of tonic clonic sz
- convulsive rhythmic symmetric mvmt
- may bite tongue or lateral cheek
- end of clonic phase -> relaxation -> incontinence
post ictal phase of tonic clonic sz
- often prolonged
- variable pd of consciousness
- initially stuporous or sleeps, gradually awakens confused/ agitated/ combative
tx of tonic clonic sz
- valproic acid
- lamotrigine
- topirimate
- phenytoin
- carbamazepine
status epilepticus
- sz > 5-10 min or 2 sz without lucid interval
- assumes ongoing sz activity during time of diminished responsiveness
- can involve any type of sz
why is status epilepticus dangerous
- high mortality rates if > 60 min
- brain uses more energy than can be supplied -> neurons become exhausted and dont function
when should you suspect status epilepticus
- if AMS does not improve in 20-40 min s/p sz
- consider stat EEG
which type of status epilepticus is most dangerous
- tonic clonic
- cause:
- ventilatory insufficiency, hypoxemia
- cardiac arrhythmias
- hyperthermia
- systemic lactic acidosis
common causes of status epilepticus
- med withdrawal or non-compliance
- most common in very young or old
- stroke most common cause in elderly
medication options for acute sz
- lorazepam IV or diazepam IV
- midazolam IM if no IV access
- phenytoin IV
- fosphenytin IV (faster infusion rate but $$)
- valproate IV
- induce coma with midazolam, propofol, phenobarbitol
lorazepam vs. diazepam for acute sz tx
- lorazepam has no upper limit of dosing
- lorazepam lasts longer than diazepam
- diazepam has faster onset
- diazepam has risk of respiratory depression and hypotension
etoh induced seizure
- usu occurs 6-48 hours after last drink/ cutting back
- may have multiple sz
- consider admission for 1-2 days
tx for etoh induced sz
- BZDs
- phenobarbitol
- detox
- CIWA scale for lorazepam admin
sz in pregnancy
- think eclampsia**
- urgent OB consult
- mag sulfate then lorazepam/ diazepam
febrile sz
- common benign condition in pds
- brief generalized sz in otherwise healthy kid
- d/t bacterial or viral illness + fever
simple febrile sz
- < 15 min
- fever 100.4+
- 6 mo- 5 years
- only 1 sz in 24 hours
complex febrile sz
- > 1 in 24 hours
- any focality to sz
- outside of 6mo-5 yrs
- duration > 15 min
work up for simple sz in well appearing child
- underlying illness work up only*
- no imaging/ LP/ consults
work up for complex sz and/or ill appearing child
- CBC
- UA/UC
- blood cx
- cxr
- LP
- abx immediately
treatment of febrile sz
- does NOT require AED
- antipyretics do not rduce risk of sz
- 50% likely to have repeated febrile sz
psychogenic non-epileptic seizure (PNES)
- aka pseudoseizure
- resembles seizure but psych causes
- assoc with PTSD, personality disorder, depression
- 40% of pts with sz disorder also have PNES
conversion disorder
- psychiatric somatoform disease
- functional neuro sz disorder
- psychological stress is displayed in physical ways
dx of PNES
- resistant to AEDs
- EEG video monitoring for definitive dx
- time to sx is usu 7-10 years
si/sx of PNES
- side to side head shaking
- asynchronous, nonrythmic or sterotypical motor mvmt
- stuttering
- weeping
- preserved awareness, no post ictal phase
- eye flutter, eyes held shut
- back arching
- pelvic thrusting
- episodes impacted by bsystanders
management of PNES
- generally tx if irreversible precipitant
- if unprovoked may recur
- no evidence for need to treat with AED after 1st unprovoked sz
- consult neuro
- admin AEDs with lower ADR profiles
