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CNS Module: Exam 2 > Seizures > Flashcards

Seizures Flashcards

1
Q

Seizure Definition

A

isolated clinical event, transient

–> abnormal electrical brain activity

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2
Q

What define a provoked seizure?

A
  • medications (bupropion, tramadol)
  • substance use/withdrawal (alcohol use disorder)
  • metabolic factors (anorexia)
  • acute brain injury
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3
Q

What define an unprovoked seizure?

A
  • idiopathic
  • epileptic
  • remote symptomatic (secondary to something at least 7 days old)
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4
Q

Epilepsy Definition

A
  • chronic disorder

- 2+ unprovoked seizures at least 24+ hours apart

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5
Q

What is a reflex seizure?

A

Epileptic event secondary to some stimuli (motor, cognitive, or sensory)

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6
Q

Which medications are associated with seizure?

A
  • bupropion
  • antipsychotics
  • stimulants (amphetamines, cocaine)
  • lithium
  • some opioids (tramadol, merperidine)
  • varenicline
  • some antibiotics (carbapenems, quinolones)
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7
Q

What happens in the brain?

A

imbalance between excitatory (glutamate) and inhibitory (GABA) actions of the brain

TOO much excitatory, too little inhibitory

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8
Q

Tonic Seizure Definition:

A

stiffness

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9
Q

Clonic Seizure Definition:

A

convuslsions/jerk

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10
Q

myoclonic Seizure Definition:

A

muscle jerk/short twitches

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11
Q

Atonic Seizure Definition:

A

relaxed/limp

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12
Q

Tonic-Clonic Seizure Definition:

A

stiffness followed by convulsions

Gran-Mal seizure

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13
Q

Absence Seizure Definition:

A

loss/regain consciousness for a brief period

Petite-Mal Seizure

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14
Q

Types of seizures: focal/partial

A

originate in one hemisphere

  • simple partial: remain conscious
  • complex partial: unocnscious or impaired awareness/responsiveness

(may experience motor or non-motor symptoms)

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15
Q

Types of seizures: Generalized

A

both hemispheres
AND
loss of consciousness

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16
Q

Types of seizures: Status Epilepticus

A

5+ minutes of seizure activity
OR
recurrent seizures without return to baseline between seizures

(this can be any seizure)

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17
Q

Risk Factors

A
  • family history
  • prolonged lack of sleep
  • alcohol/drug misuse
  • prescription medications
  • metabolic issues (hypo/hyperCa, hypoglycemia, hypoNa)
  • complications during pregnancy/delivery
  • traumatic brain injury (concussion)
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18
Q

What is needed for a diagnosis?

A
  • physical exam
  • detailed history from pt or witness of sx
  • complete neurological exam
  • medication hx
  • Labs (BAC, tox screen, pregnancy)
  • EEG & brain imaging
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19
Q

Seizure first aid:

A
  1. assess the situation
  2. get pt to ground c/ something under their head
  3. recovery position!
  4. remove glasses/ things that could constrict their neck
  5. TIME (no improvement in 5 mins = 911)
  • DO NOT:
  • prevent pt from moving
  • put something in their mouth
  • let them drink/eat until fully alert
  • DO:
  • stay with pt until EMS arrives
  • be comforting (they can be conscious!)
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20
Q

When is a patient at extra risk?

A
  • pregnancy
  • being in water
  • unable to wake after seizure
  • aggressiveness
  • PMH DM
  • more than 1 seizure in a row
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21
Q

When are they hospitalized?

A
  • recurrent seizures
  • seizure secondary to infection, injury, or tox
  • seizure + fever
  • loss of consciousness
  • lack of social support @ home

these pts are always seen/ managed by NEUROLOGY

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22
Q

What is classified as an Acute Seizure?

A

lasting < 2 mins; no pharm intervention necessary

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23
Q

Tx: Acute Seizure Management

A

IF tx needed: BENZOS (IV)
- lorazepam: fast acting, short lasting (repeat q5-10m prn)

  • EMS situation: IM midazolam (can be effective)
  • recurrent seizure: rectal diazepam (can be effective)
  • advanced case: intranasal benzo
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24
Q

What is the key thing we need to remember with Status Epilepticus?

A

MAINTAIN an AIRWAY
DO NOT give paralytic agents

Medical emergency

25
Q

Tx: Status Epilepticus

A

Initial: IV short acting benzos (lorazepam)
- may use alt route if no IV access
(IM midazolam is backup)

Follow up: reduce risk of relapse with long-acting anti-seizure med

remember: correct potential nutritional causes
- IV glucose if hypoglycemic (< 70)
- IV thiamine (alcohol use disorder)…banana bag

26
Q

So what meds do we want to use with status epilepticus?

A
  • VPA
  • phenytoin
  • fosphenytoin
  • continuous infusion of midazolam
  • phenobarbital
  • levetiracetam

LONG ACTING ANTI-SEIZURE MEDS

27
Q

When do we start Chronic Seizure Management?

A

after evaluation & diagnosis by neurologist
(first-time seizure is not always indication to start tx)

  • meds usually started after 2nd UNPROVOKED or REFLEX seizure
    (or status epilepticus)

WANT MONO TX

28
Q

First line tx options for: partial/focal

A
  • carbamazepine
  • lamotrigine
  • keppra
  • oxcarbazepine
  • topamax
  • zonisamide
29
Q

First line tx options for: generalized tonic-clonic

A
  • lamotrigine
  • levetiracetam
  • VPA
  • topamax
  • zonisamide
30
Q

First line tx options for: abscense

A
  • ethosuximide

- VPA

31
Q

First line tx options for: myoclonic, atonic, atypical

A
  • ethosuximide
  • lamotrigine
  • levetiracetam
  • VPA
32
Q

ADR of interest

A
  • pregnancy: teratogenic
  • dizziness: fall risk
  • mental status changes: evaluate thoughts of harm @ each visit
  • incr. risk of osteoporosis
33
Q

Carbamazepine

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
A
  1. partial/focal, generalized tonic-clonic
  2. SJS/TEN, aplastic anemia and agranulocytosis
    - HLA-B*1502 allele (Asian ancestry)
  3. PMH bone marrow suppression, hypersensitivity to TCAs, use w/i 14d of MAOi
    - avoid in pregnancy (spina bifida, developmental disorders & congenital abnormalities)
  4. slow PO uptake (present 3-4 hrs after dose)
  5. 4 - 12 mcg/mL
34
Q

ADR: Carbamazepine

A
  • dizzyness/headache
  • upset stomach/constipation
  • change in appetite
  • hypoNa (monitor @ baseline, 1 mo later, periodically)
35
Q

Oxcarbazepine

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
A
  1. partial/focal ONLY
    - very similar to carbamazapine
  2. weak inducer of CYP 3A4 (carbamaz is strong)
    - decr. concentrations of PO contraceptives (need additional form of non-hormone contraception)
36
Q

Levetiracetam

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. partial, myoclonic, generalized tonic-clonic
    * adjunctive agent
  2. no sig. CI or drug interactions
  3. monitor CNS issues
  4. monitoring serum levels not recommended
37
Q

Levetiracetam ADR

A
  • upset stomach
  • dizzy
  • asthenia
  • irritability

more alert? (reported)
low chance of SJS / TEN

38
Q

VPA/DVP

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. complex partial, generalized absence
    * monotx or adjunctive
  2. hepatotoxicity (mostly 1st 6 mo), pancreatitis, teratogenic (neural tube defects/other malformations)
  3. hepatic disease/dysfunction
    - CYP inhibitor
  4. depakene=IR; depakote=ER (mania secondary to bipolar, migraine prophylax)
  5. 50 - 100 mcg/mL (trough levels w/i 3-4 days of starting/adjusting the dose)
  6. monitor LFTs at baseline & frequently in 1st 6 mo
    - watch baseline CBC & periodically after

DO NOT change mnfct/prod. –> incr seizure risk

39
Q

ADR VPA/DVP

A
  • alopecia
  • wt gain
  • V/D
  • upset stomach (help when taken c food)
  • dose related thrombocytopenia
  • asthenia
  • tremor (worsen c anxiety or caffeine)

DO NOT use in pregnancy

40
Q

Lamotrigine

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. ADJUVANT tx: partial-onset, generalized tonic-clonic, Lennox-Gastaut Syndrome
    - can be 2nd line monotx in partial-onset seizures
    - bipolar disorder
  2. SJS / TEN
    - any rash, pt should d/c drug
    - exacerbated by: VPA, starting above recommended dose or incr. too quickly
  3. no CI, just watch VPA c lamictal –> inhibits lamictal metabolism (smaller doses necessary)
  4. may cause prolonged ventricular contraction
    - avoid if: heart block, ischemia, heart failure, structural heart disease
  5. liver & renal funct. tests & CBC, other anti-seizure med levels
    (do NOT monitor lamictal)
41
Q

ADR Lamotrigine

A
  • N
  • upset stomach
  • dizzy
  • blurry vision
  • dose-related rash (d/c immediately)
42
Q

Lamotrigine dosing

A

starter packs for 1st 5 wks

blue = low dose
- VPA

orange = normal dose
- no meds under blue OR green

green = high dose

  • carbamazepine
  • phenytoin
  • phenobarbital
  • primidone
43
Q

Phenytoin

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. complex partial, generalized tonic-clonic, prevention/tx during/ following neurosurgery
    - potent inducer; highly protein bound
  2. IV formulation: no > 50 mg/min OR 1-3 mg/kg/min in pediatric pts –> hypotension & arrhythmia
  3. IV form: sinus bradycardia, 2/3 degree heart block
  4. separate from antacid/dairy by 1 hour; ETOH decr levels
  5. 10-20 mg/L
    - steady state 5-10 d
  6. CBC, CMP, albumin, VitD
  • may make absence or myoclonic seizures worse
44
Q

ADR phenytoin

A
  • low grade tremor
  • der. coordination
  • confusion
  • speech issues
  • trouble concentrating
  • gingival hypertrophy
45
Q

Above what level can phenytoin actually cause seizures?

A

30 mg/L

46
Q

What would happen to phenytoin levels with a low albumin (<3.5 g/dL)?

How do we calculate phenytoin?

A

higher FREE phenytoin levels (highly protein bound!!)

phenytoin level = lab level/ [(0.2 x alb) + 0.1]

47
Q

Phenobarbital

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. partial, generalized tonic-clonic, status epilepticus
  2. severe hepatic disease
    - -> caution: PMH substance use disorder (GABA agonist)
    * AVOID in PREGNANCY (cognitive effects)
  3. potent CYP inDucer
  4. CBC, CMP (ONLY if AE present)
48
Q

ADR Phenobarbital

A
  • agitation
  • confusion
  • constipation
  • hallucinations
  • mood changes
49
Q

Ethosuximide

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
  6. monitoring
A
  1. ABSENCE only
  2. 40-100 mcg/mL
  3. CBC, LFTs, trough level prn
50
Q

ADR Ethosuximide

A
  • upset stomach
  • mood change
  • headache
  • N/V
  • psychosis
  • SJS, aplastic anemia, agranulocytosis (possible, but rare)
51
Q

Topamax

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
A
  1. partial, generalized tonic-clonic (monotx or adjunct)
    - migraine prevention, wt loss, nerve-based pn (also used)
  2. DO NOT use c PREGNANCY (cleft lip/plate)
52
Q

ADR Topamax

A
  • dizzy
  • confusion
  • kidney stones
  • wt LOSS

(take HS to decr. AE)

53
Q

Zonisamide

  1. indication:
  2. BBW?
  3. CI:
  4. *:
  5. reference range
A
  1. focal IF 16+ yo (adjunct)

3. sulfonamide allergy

54
Q

ADR Zonisamide

A
  • agitation
  • confusion
  • fatigue
  • nausea
  • kidney stones
55
Q

How/When do we switch seizure meds?

A
  1. make sure they were on the right: dose, level, amt of time
  2. verify AE present that is dangerous or (-) impact QoL
  3. do not make a hard change
  4. counsel pts to be adherent & follow instructions (can take time (months) to get right!)
56
Q

Are there non-pharm options?

A

YES

  • surgery (really great if drug-resistant, usually caused by tumors)
  • laser tx
  • vagal nerve stimulation
  • direct brain stimulation
57
Q

Seizure + Pregnancy Tips

A
  • verify pregnancy status EVERY visit
  • no “perfectly safe” anti-seizure med
  • use folic acid prior to pregnany
  • DO NOT use VPA
  • if cont. tx –> check levels regularly
  • counsel on effective birth control methods (if pt does not want to get pregnant) bc some COC are effected
58
Q

Seizure + Driving Tips

A

seizure free for a set period of time before being allowed to drive
- 6 mo in PA

usually need documentation by physician

CNS Module: Exam 2 (8 decks)

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