Seizure

Question 1

what are the 3 categories of seizure

Answer 1

generalized, partial, complex partial

Question 2

what is the definition of status epilepticus?

Answer 2

Continuous or intermittent seizure activity for >5 min without regaining consciousness. (May include continuous generalized sz, recurrent generalized with depressed LOC between, etc)

Question 3

By what time frame should status epilepticus be terminated by to optimize the chance of avoiding permanent neurological sequelae?

Answer 3

30 min (beyond this, may have permanent neuronal damage)

Question 4

What is a ‘generalized’ seizure?

Answer 4

implies simultaneous discharge of the entire cerebral cortex with concomitant loss of consciousness. Sz activity may originate globally or spread from a focal source.

Question 5

What are the large general categories to think of as precipitants of seizure?

Answer 5

Drugs/EtOH, Infection, Metabolic, structural, epilepsy, pregnancy (eclampsia)

Question 6

Drugs to think of as seizure precipitants

Answer 6

Withdrawal: anti-convulsants, EtOH, benzos, barbiturates.
Ingested: Anticholinergics, sympathomimmetics, ASA, salicylates, Lithium, lidocaine, many others.

Question 7

‘Structural’ precipitants

Answer 7

tumors/mets, hemorrhage, stroke, AVMs, post-traumatic brain injury

Question 8

‘Infection’ seizure precipitants

Answer 8

meningitis, abscess, encephalitis

Question 9

‘Metabolic’ seizure precipitants

Answer 9

hypoglycemia, hyper/hypo-Na, hypocalcemia, severe lactic acidosis, uremia, hypomagnesemia

Question 10

What percentage of patients with new onset generalized seizures will have an episode of status epilepticus in 5 years?

Answer 10

20%

Question 11

What is the mortality rate of first episode status epilepticus

Answer 11

up to 20-30% (typically due to underlying cause)

Question 12

Which patients are more likely to experience non-convulsive status epilepticus

Answer 12

Those with extensive brain injury (e.g. large intracranial hemorrhage, hypoxic CNS injury)

Question 13

What questions are important from history?

Answer 13

time of onset, hx of seizures, ingestions, associated symptoms (HA,fever), PMHx (Ca, TB, substance use, preg hx, etc)

Question 14

What signs help distinguish a seizure from other possible diagnoses (e.g. syncope, etc)

Answer 14

Sz: abrupt onset, ‘foaming at mouth,’ tongue biting, urine or fecal incontinence, post-ictal state of decreased LOC lasting 20-30 min

Question 15

Discuss approach to airway in seizures

Answer 15

Most pts will be unable to protect their airway and/or are hypoxic and require intubation. Those that do not require immediate intubation are likely to become very sedated from medications and ultimately require definitive management. Give supplemental O2, start with NPA/OPA and mask if able and be prepared to secure definitive tube.

Question 16

What labs/tests should you get

Answer 16

Immediate ACCU. CBC, lytes, anticonvulsant levels, VBG, Ca, Mg, EtOH level, salicylate level, Utox.
ECG, LP, CT head

Question 17

Describe initial management of a seizure

Answer 17

Airway mgmt, oxygen, establish IVs, cardiac monitoring, IVF. Check ACCU, if low give 1 amp D50.
Establish IO access if IV access not possible.

Question 18

What drugs will you give for seizure? (70 kg adult)

Answer 18

Benzos:

1) Ativan 2-4 mg IV q2 min, max 8-10 mg
2) Diazepam 5-10 mg IV, max 20-30mg
3) Midazolam 10 mg IM if IV not available.

If seizure activity fails to resolve in 5-10 min, in 2nd IV line give:
Dilantin 20 mg/kg IV at rate of 25-50 mg/min (can repeat 10 mg/kg dose)

If still maxed and seizure activity continues consider:

1) Midaz infusion 0.2 mg/kg IV loading dose then infusion at 0.5 mg/kg/hr
2) Propofol 2-5 mg/kg IV loading dose then 2-10 mg/kg/hr

Question 19

Describe non-CNS complications of SE

Answer 19

Cardiovascular stress: may be worsened by anticonvulsant. May include MI arrhythmia, cardiac arrest.
Hypotension: due to sz or drugs.
Resp failure: due to sz or drug therapy.
Repeated muscle ctx: rhabdo, hyperthermia.
Increased PNS activity: sweating, salivation and bronchial hypersecretion.
Non-cardiogenic pulmonary edema.