Seizures Flashcards
definition of a seizure
transient episode of abnormal excessive neuronal activity results in sudden change in behavior, sensory perception, or motor activity
primary seizure is…
unprovoked
secondary seizure is…
provoked
definition of epilepsy?
recurrent (>2) unprovoked seizures
differences b/w generalized seizure and partial (focal) seizures?
Generalized seizures
- Affects entire brain
- LOC
Partial (focal) seizures
- Affects a specific area of brain
- Simple -> no LOC
- Complex -> LOC or altered consciousness
what are the 2 classifications of Partial (focal) seizures?
simple and complex
partial seizures can become what type of seizures?
generalized seizures
difference b/w simple partial (focal) sz and complex partial (focal) sz in terms of consciousness?
simple has NO LOC (awake during the seizure)
complex does
what are the motor sx’s of simple partial (focal) sz?
jerky, rhythmic movements that may remain restricted to one body segment or spread by “jacksonian march” (along homunculus of motor sensory parietal lobe)
what is the “Jacksonian March “ in simple partial (focal) sz?
Have abnormal neuronal activity that starts in the thumb, moves into the digits, then hand, then elbow, then shoulder, all the way up to the homunculus “marching its way up to the homunculus”
do simple seizures resolve with increase in age?
YES!!! - resolve by age 16 y/o
what are the sensory/experiential sx’s of simple partial (focal) sz?
tingling/electric shock, numbness, auditory (buzzing, ringing, drumming), olfactory (unpleasant odor), gustatory
deja vu and jamais vu
visual hallucinations
what is the tx for simple partial (focal) sz?
no one drug of choice
when is surgery a tx for simple partial (focal) sz?
refractory seizures
documented video EEG and corresponding lesion on neuroimaging -> do ablative procedure of the specific area
do pts with complex partial sz remember the sz or don’t remember it compared to simple partial sz?
they don’t remember it -> HAVE LOC
how does complex partial sz begin? followed by?
behavioral arrest and is followed by staring, automatisms, and postictal confusion
what are automatisms?
nonpurposeful, stereotyped, and repetitive behaviors
Chewing, lip-smacking, fumbling w/ hands, picking, mumbling
what occurs before complex partial sz?
aura
what sz has an aura precede it 80% of the time?
temporal lobe seizures
what’s the difference b/w frontal lobe origin and temporal lobe origin sz?
Frontal lobe
-bizarre motor behavior such as fencing, bicycling
Temporal lobe
-aura and/or complex partial sz
what is an absence seizure?
Brief generalized Sz w/ impaired consciousness (i.e. staring episode, confused, detached, withdrawn) but no aura, post-ictal period or loss of postural tone
absence seizure aka…
petit-mal
how long do absence seizures last and how many can you have up to in 1 day?
<20 secs and can have up to 100/day
what does absence sz usually look like?
child is staring, confused, detached, withdrawn
who get absence sz?
school aged children (childhood/adolescence)
what are triggers of absence sz?
hyperventilation and light
tx for absence only sz?
Ethosuximide
tx for absence sz that occurs with other sz types?
valproic acid, topiramate, lamotrigine
what is a myoclonic sz?
brief arrhythmic jerking motor movements that last less than 1 second and often cluster within a few minutes
when are myoclonic jerks a normal release?
during phase 1 of sleep
what is a tonic seizure? occurs in relation to what?
sudden-onset tonic extension or flexion of the head, trunk, and/or extremities for several seconds
Typically occur in relation to drowsiness (just s/p falling asleep or waking)
what is a clonic seizure? involves what extremities? common or rare in isolation? seen in who?
Rhythmic jerking motor movements with or without impairment of consciousness
Typically involve simultaneous upper and lower extremities
Rare to have this in isolation (w/out tonic phase) and typically babies
what is an atonic seizure? lasts how long?
“Drop attacks” = brief loss of postural tone
Multiple falls and injuries often these pts wear helmets; patient born with this
<15 sec
tx of myoclonic, tonic, clonic, atonic seizures?
- Valproic acid
- Lamotrigine
- Topiramate
- Levetiracetam (adjunct)
what med MUST be used in adjunct for seizure tx?
Levetiracetam
tonic-clonic primary generalized seizures aka…
grand-mal seizures
how do tonic-clonic sz present?
several motor behaviors lasting 1-2 minutes
prodromal ictal cry
tonic phase is…
10-20 sec extension extremities + neck w/ flexion of the trunk w/ apnea and cyanosis
clonic phase follows ___ and is…
• Clonic phase follows tonic phase w/ convulsive rhythmic symmetric movements
-tongue biting/cheek (lateral tongue biting)
what is a classic sign of a sz?
LATERAL TONGUE BITING
what happens at the end of clonic phase with relaxation?
urinary incontinence
is urinary incontinence a good sign to look for when trying to delineate b/w syncope and seizure?
NO!!! - can occur in both!!!
does tonic-clonic sz have aura?
No aura but many have prodrome (premonition that they will have a seizure)
tx of tonic clonic sz?
- Valproic acid
- Lamotrigine
- Topiramate
- Zonisamide
are the 4 phases of a sz?
prodromal, preictal or aura, octal, postictal
what is the prodromal phase of a sz?
premonition prior to seizure
Mood changes, sleep disturbances, lightheadedness, anxiety, irritability, difficulty concentrating
Hours-days before sz
what is the preictal or aura phase of a seizure?
Prior to seizure w/ sensory or experiential warning can be hours-days before sz
also have preictal cry
what is the ictal phase of a seizure?
during seizure
what is the postictal phase of a seizure?
after seizure
typical sx’s of postictal phase of seizure?
can have no sx’s or…
- memory loss
- confusion/agitation
- difficulty talking
- headache
what are the metabolic and electrolyte imbalances that can precipitate a seizure?
- hyponatremia (<120)
- hypocalcemia
- hypomagnesmia
- hypoglycemia
what’s the hyponatremia dependent on?
the speed at which the sodium level comes down
hypoglycemia (seizure precipitant) isn’t seen in who?
T2DM
what is one thing you should always do with a seizure patient?
CHECK THEIR GLUCOSE LEVELS
what are the drugs/meds can precipitate a seizure?
- cocaine, amphetamines
- herbal remedies, Ephedra
- Epileptiform meds/antidepressants (I.e. Wellbutrin)
- IV drug us
what well known antidepressant can precipitate a seizure?
Wellbutrin
what drug withdrawals can precipitate a seizure?
ETOH withdrawal w/in 6-48hrs
benzo withdrawal
what is the M/C cause of seizures in kids?
fevers
what other stressors can precipitate a seizure?
sleep deprivation and stress
what can be the first sign of alcohol withdrawal?
seizure
when do seizures in alcohol withdrawal usually occur?
1-2 days after alcohol withdrawal
what is the most important question you want to determine about a patient that is having a seizure?
is the current seizure the same or is it a new type of seizure?
what is something a seizure can mimic?
syncope
also psychogenic non-epileptic seizures (PNES)
syncope vs seizure
5x more likely sz if post-ictal confusion (if wake up and totally find, then syncope)
3x more likely to be sz if <45 y/o
tongue biting, rhythmic shaking and dystonic posturing, aura
unilateral head turning (need witness)
when are lactate and prolactin elevated in a seizure?
in 1st hour of seizure
what is status epileptics?
seizure >5-10 mins
2 seizures w/out a lucid interval
most serious complication of epilepsy/seizures (esp tonic-clonic seizures b/c become acidotic)
what is happening to the brain during status epilepticus?
brain is using more energy than can be supplied
neurons become exhausted and cease to function
what is the most dangerous type of status epilepticus?
tonic-clonic seizures
what are the 2 most common causes of status epilepticus in adults?
sub therapeutic anti epileptic drugs and cerebrovascular disease (stroke)
if pt that had status epilepticus and AMS doesn’t improve after 20-40 min, what should you consider?
that they are having a subtle SE -> need stat EEG
what’s the first step in treating acute seizure?
protect airway and check glucose
what meds will stop an acute seizure and give you enough time to prevent another one?
lorazepam, diazepam, midazolam (this one is better IM)
how often can you give lorazepam?
prn -> can keep on giving until the pt stops seizing
what meds do you follow-up an acute seizure with about the benzo’s?
phenytoin, fosphenytoin, leveitracetam, valproate
what else can you do for acute seizure tx?
induce coma with midazolam
then do EEG monitoring b/c need to determine if still seizing (since a coma) and if need other agents added on
if ETOH is the cause of the seizure, what’s the tx?
admit for tx (1-2 days)
treat with Benz’s, phenobarbital protocol, detox
if patient is pregnant >20 weeks and having a seizure, what is the cause? how do you treat?
eclampsia
tx:
-urgent ob consult, magnesium sulfate IV load and then drip, lorazepam/diazepam, delivery
(consider central census thrombosis as possible cause even tho rare)
what are febrile seizures?
benign, brif and generalized seizure in otherwise healthy children who have fever from viral/bacterial illness
what are the 4 criteria for a simple febrile seizure?
(1) duration <15 min
(2) fever 100.4 or greater
(3) age 6 months - 5 years
(4) only 1 sz in 24hr period
what are the 4 criteria for a complex seizure?
(1) >1 sz in 24hr period
(2) any locality to sz
(3) outside age range of simple febrile seizure (6 months-5 years)
(4) duration >15 min
if simple febrile sz what is the work-up?
underlying illness w/u only
if complex febrile sz what is the work-up?
further w/u -> CBC, UA/Cx, blood cxs, CXR, LP, abx immediately
should AEDs be started in febrile seizures?
NO
does the child have an increased risk of developing epilepsy after first febrile seizure?
YES, but only 1-2% chance
what’s the chance of having another febrile seizure after having the first one?
50% chance
does giving antipyretics decrease chance of recurrent febrile seizure?
NO!, but fever control is indicated for symptomatic relief
what are psychogenic non-epileptic seizures?
pseudoseizure
proxysmal episodes that resemble and are often misdiagnosed as epileptic seizures
psychogenic non-epileptic seizures are ___ in origin. associated with…
psychological in origin (I.e. emotional, stress-related)
associated w/PTSD, personality d/o’s, depression
what psych disorder is PNES associated with?
Conversion disorder (psychiatric somatoform disease)
difference b/w PNES and real seizure presentation?
PNES is atypical movements -> not rhythmic, have back arching, pelvic thrusting, remember the event, normal CO2 levels
PNES are resistant to ___
AED’s
what’s the definitive diagnosis of PNES?
EEG video monitoring
tx of PNES?
no evidence to treat pharmacologically after 1st unprovoked sz
consult neurology for advice and follow-up
what is seen on EEG with seizure?
spiking
what is the cornerstone of dx for epilepsy?
clinical dx
use video EEG to classify…
classify type of sz vs pseudoseizure (PNES)
what are important counseling points for seizures?
AED’s are continued for at least 1 year
Avoid precipitants (good sleep hygiene, limit ETOH intake, stress reduction)
Safety - avoid driving at least 6 months and until EEG/imaging
how long must commercial drivers be seizure-free for?
12 months
