Seizures

Question 1

Define status epilepticus

Answer 1

• a single seizure ≥5 minutes in length

or

• >2 seizures without recovery of consciousness between seizures

Status epilepticus is a neurologic emergency, and treatment should be initiated in all patients with continuous seizure activity lasting more than 5 minutes

Question 2

most common causes of status epilepticus
include

Answer 2

subtherapeutic antiepileptic levels
preexisting neurologic conditions, such as prior CNS infection, trauma, or stroke
acute stroke
anoxia or hypoxia
metabolic abnormalities
alcohol or drug intoxication or withdrawal

Question 3

True or false

After 5 minutes,
seizures are
less likely to spontaneously terminate,
less likely to be controlled with antiepileptic drugs, and
more likely to cause neuronal damage

Answer 3

True

Question 4

As seizures surpass the 5-minute mark, what dramatic changes occur at the cellular level?

Answer 4

• Decreased expression and internalization of γ-aminobutyric acid receptors, coupled with increased expression of both glutamine and N-methyl-d-aspartate receptors, lead to a great diminished seizure threshold
• The blood–brain barrier is also compromised, leading to CNS penetration of potassium and albumin, both of which are hyperexcitatory CNS chemicals

Question 5

What happens after 20 minutes?

Answer 5

• After 20 minutes, hypotension, hypoxia, metabolic acidosis, hyperthermia, hypoglycemia, cardiac dysrhythmias, and pulmonary edema frequently develop.
• This hyperexcitatory milieu makes standard antiseizure therapies much less effective in seizure termination.

Question 6

What happens in nonconvulsive status epilepticus?

Answer 6

the patient is comatose or has fluctuating abnormal mental status or confusion, but no overt seizure activity is present

Question 7

What are the findings suggestive of non-convulsive status epilepticus?

Answer 7

a prolonged postictal period after a generalized seizure

subtle motor signs such as twitching, blinking, and eye deviation

fluctuating alterations in mental status

or unexplained stupor and confusion

Question 8

The goal of treatment in status epilepticus is?

Answer 8

seizure control as soon as possible and within 30 minutes of presentation

Question 9

 why do we avoid IV fluids containing glucose?

Answer 9

as phenytoin is not compatible with glucose-containing solutions

Question 10

Initial laboratory evaluation includes

Answer 10

blood glucose, a metabolic panel including calcium and magnesium, lactate, and if appropriate, a pregnancy test, a toxicology screen, and anticonvulsant levels.

Question 11

True or false

 Do not attempt lumbar puncture during status epilepticus.

Answer 11

True

Question 12

If bacterial meningitis or encephalitis is suspected clinically, then

Answer 12

immediately start empiric antibiotic or antiviral therapy

Question 13

Which drug is still considered the initial agent of choice if IV access is available?

Answer 13

IV lorazepam

Question 14

In established status epilepticus, follow benzodiazepines with longer- acting antiepileptic agents:

Answer 14

fosphenytoin or phenytoin; levetiracetam; valproate; or lacosamide

Question 15

One of these antiepileptic agents should be started within _________of diagnosis

Answer 15

20 minutes

Question 16

This drug is effective but has serious side effects; the Food and Drug Administration has issued a black-boxed warning for hepatic failure and pancreatitis, and should not be administered along with phenytoin

Answer 16

Valproic acid

Question 17

This drug is very effective, is quick to administer, and has few interactions and side effects.

The precise mechanism of action is unknown, but it may inhibit voltage-dependent calcium channels and facilitate γ-aminobutyric acid inhibitory transmission.

it is rapidly gaining favor as a first- line drug for established status epilepticus

Answer 17

Levetiracetam

Question 18

Mechanism of action of Levetiracetam

Answer 18

inhibit voltage-dependent calcium channels and facilitate γ-aminobutyric acid inhibitory transmission

Question 19

Dose of levetiracetam

Answer 19

20 to 60 milligrams/kg IV

Question 20

Refractory status epilepticus is defined as

Answer 20

persistent seizure activity despite the IV administration of adequate amounts of two antiepileptic agents and usually exceeds 60 minutes

Question 21

First line agent for refractory status epilepticus

Answer 21

Propofol

Question 22

Second line agent for refractory status epilepticus

Answer 22

Midazolam

Question 23

Third line agents in the refractory status epilepticus

Answer 23

Barbiturates, such as phenobarbital (up to 20 milligrams/kg IV) or pentobarbital

Question 24

Third Line agent in refractory status epilepticus

Answer 24

ketamine

Question 25

Mechanism of action of ketamine

Answer 25

N-methyl-d-aspartate receptor antagonist and helps block the hyperexcitatory pathway

Question 26

Give the treatment for status epilepticus

Answer 26

Question 27

A transient focal deficit (usually unilateral) following a simple or complex focal seizure is referred to as________________ and should resolve within __________

Answer 27

Todd’s paralysis 48 hours

Question 28

Clinical features that help to distinguish seizures from other nonseizure attacks include the following

Answer 28

• Abrupt onset and termination most attacks begin abruptly Most seizures last only 1 or 2 minutes • Lack of recall • Purposeless movements or behavior during the attack • postictal confusion and lethargy

Question 29

Differential diagnosis of seizures

Answer 29

Syncope pseudo seizures hyperventilation syndrome movement disorders migraine

Question 30

In a patient with a well- documented seizure disorder who has had a single unprovoked seizure, the only tests that may be needed are _____________ and _______________.

Answer 30

glucose level pertinent anticonvulsant medication levels

Question 31

These tests can prove helpful in distinguishing true seizures from a pseudoseizure

Answer 31

A seizure may result in a lactate-driven, wide anion gap metabolic acidosis. Most lactate abnormalities will clear within 30 minutes. The prolactin level may also be elevated for a brief period (15 to 60 minutes) immediately after a seizure.

Question 32

the most common cause of a breakthrough seizure

Answer 32

A very low serum anticonvulsant drug level suggests medication noncompliance

Question 33

Lumbar puncture in the setting of an acute seizure is indicated if

Answer 33

the patient is febrile or immunocompromised or if subarachnoid hemorrhage is suspected and the noncontrast head CT is normal.