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Block 8 Week 5 Colt > Seizures - Bloch > Flashcards

Seizures - Bloch Flashcards

1
Q

seizures are (hyper/dys)synchronous discharge

A

hypersynchronous

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2
Q

seizures arise from (cortical/deep) neurons

A

cortical

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3
Q

How many unprovoked seizures are necessary to have epilepsy?

A

two more more

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4
Q

What fraction of all seizures are febrile convulsions

A

1/3

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5
Q

What is the lifetime incidence of seizures?

A

9%

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6
Q

what percent of patients with new onset seizures will have epilepsy?

A

60%

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7
Q

to have epilepsy, your seizures cannot be caused by…

A

EtOH or sedative withdrawal
metabolic disorders
nonketotic hyperglycemia

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8
Q

What are the types of partial seizures?

A

simple partial
complex partial
secondarily generalized

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9
Q

what are the types of generalized seizures?

A 
Absence
myoclonic
Atonic
Tonic
Tonic-clonic
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10
Q

Dx of a type of epilepsy is based off of….

A

clinical history and seizure type

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11
Q

in what type of partial seizure is consciousness preserved?

A

simple partial

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12
Q

in what type of partial seizure is the person able to pay attention, and respond to questions and commands?

A

simple partial

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13
Q

In what type of partial seizure is consciousness lost?

A

complex partial

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14
Q

in what type of partial seizure is the memory of the seizure lost?

A

complex partial

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15
Q

in what type of partial seizure must driving be reistricted?

A

complex partial

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16
Q

partial onset seizures may progress to what?

A

secondarily generalized

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17
Q

Secondarily generalized seizures involve motor activity on (blank) sides of the body

A

both sides; makes it hard to tell if it is pimarily generalized

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18
Q

What are some of the clinical features of simple partial seizures?

A
  1. somatosensory or special Sx
  2. with motor signs
  3. with autonomic Sx or signs
  4. with psychic or experiential Sx
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19
Q

Presence and nature of aura, automatisms, and motor activity vary with what factors in complex partial seizures?

A

site of origin

degree of spread

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20
Q

what is the duration of a complex partial seizure?

A

less than two minutes

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21
Q

where do most complex partial seizures start/

A

temporal lobe

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22
Q

T/F: complex partial seizures can affect consciousness while still remaining focal

A

true

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23
Q

what is the first thing patients tend to do in a complex partial seizure?

A

stare off

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24
Q

what are automatisms?

A

commonly involve the mouth

lip smacking, chewing, swallowing, fumbling, picking, vocalizations, complex acts; done automatically

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25
Q

how long does post-ictal confusion last in complex partial?

A

less than 15 minutes

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26
Q

how long may fatigue and other Sx last after a complex partial seizure?

A

hours

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27
Q

T/f: Secondarily generalized seizures may begin with or without focal neurologic symptoms

A

true

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28
Q

Describe the tonic and clonic phases of secondarily generalized/

A

variable symmetry, intensity, and duration of the phases

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29
Q

How long does a secondarily generalized last?

A

1-3 minutes

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30
Q

what are the after effects of a secondarily generalized?

A

postictal confusion
somnolence
with or without transient focal deficit

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31
Q

what three things can distinguish a secondarily generalized from primary?

A
  1. history
  2. EEG
  3. neuro exam
  4. CT or MRI
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32
Q

(1ry/2ry) generalized will have an aura prior to convulsing

A

2ry

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33
Q

What is Todd’s paralysis?

A

focal weakness on the side contralteral to 2ry generalized seizure onset

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34
Q

Describe the EEG in simple partial seizures?

A

localized or lateralized abnormal rhythmic activity

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35
Q

the EEG in complex partial seizures is rhythmic and (uni/bi)lateral

A

bilateral

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36
Q

Describe the EEG in 2ry generalized seizures?

A
  1. rhythmic activity
  2. high amplitude
  3. bilateral and diffuse
  4. can be obscured by artifact from abundant muscle activity
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37
Q

what does an EEG look like immediately post-ictal?

A

FLATLINE; the neurons have spent all of their energy and neurotransmitter

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38
Q

what type of seizure affects both hemispheres from the beginning?

A

generalized

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39
Q

T/F: all generalized seizures result in some loss of consciousness

A

true

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40
Q

What type of seizure has a petit mal staring spell and impairment of awareness?

A

absence seizures

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41
Q

how long do absence seizures last?

A

3-20 seconds

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42
Q

Absence seizures have (sudden/prolonged) onset and resolution

A

sudden

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43
Q

What provokes absence seizures?

A

hyperventilation

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44
Q

What is the age that absence seizures typically onset?

A

between 4 and 14

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45
Q

By what age do absence seizures normally resolve?

A

18

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46
Q

T/f: children with absence seizures show developmental delays in langauge

A

false; normal development and intelligence

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47
Q

What is the hallmark EEG in absence seizures?

A

3hz spike-wave discharge

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48
Q

Do absence seizures have a postictal period?

A

nope

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49
Q

How do you distinguish between absence seizure and complex partial seizures?

A

absence does not have a post ictal period

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50
Q

If an absence seizure lasts more than ten seconds, what tends to also happen/

A

motor phenomena (eye blinks, automatic movements, changes in muscle tone)

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51
Q

What are the different characteristics of an atypical absence seizure?

A

generally not provoked by hyperventilation
onset after 6 years old
IN KIDS WITH GLOBAL COGNITIVE IMPAIRMENT
GRADUAL onset over seconds

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52
Q

describe the EEG in aytpical Absence seizures?

A

slow spike-wave complexes at less than 2.5hz

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53
Q

Pts with atypical absence seizures also have what two types of seizures?

A

atonic and tonic seizures

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54
Q

What is the EEG like in myloclonic seizures?

A

4-6 hz polyspike-wave and slow wave discharges

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55
Q

describe the presentation of a myoclonic seizure?

A

bilateral, synchronous jerks of the neck, shoulders, upper arms, body, and upper legs

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56
Q

is consciousness impaired in myclonic seizures?

A

no

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57
Q

how long does a myoclonic seizure last?

A

less than 1 second

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58
Q

if myoclonic seizures happen in succession, they are called….

A

clonic seizures

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59
Q

is there altered awareness in clonic seizures?

A

yes

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60
Q

describe the presentation of tonic seizures?

A

symmetric, tonic muscle contraction of extremities with tonic flexion of waist and neck

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61
Q

how long do tonic seizures last?

A

2-20 seconds

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62
Q

Describe the EEG in tonic seizures?

A

sudden attenuation with generalized, low voltage fast activity (most common)
OR
generalzed polyspike-wave

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63
Q

Describe the presentation of atonic seizures?

A

sudden loss of postural tone
severe = falls
mild = head nods or jaw drops

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64
Q

Atonic or tonic seizures and atypical absence are most common in people with….

A

other neurologic abnormalities

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65
Q

In contrast to partial motor seizures, tonic seizures are generalized and involve (blank) musculature

A

bilateral musculature in a symmetric or near symmetric manner

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66
Q

when do tonic seizures normally occur?

A

during sleep

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67
Q

how long do atonic seizures normally last?

A

several seconds, not longer than a minute

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68
Q

What does the EEG look like in an atonic seizure?

A

electrodecremental response; sudden diffuse attenuation or generalized polyspike wave

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69
Q

Epileptic drop attacks occur with what other seizures besides atonic?

A

myoclonic or tonic if the legs are involved

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70
Q

is consciousness impaired in atonic seizures?

A

yes

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71
Q

what type of seizures are grand mal?

A

primary generalized tonic-clonic

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72
Q

How long do grand mal last?

A

30-120 seconds

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73
Q

Does the tonic or clonic seizure happen first?

A

tonic phase

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74
Q

What happens in the tonic phase of grand mal?

A

stiffening and fall

ictal cry

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75
Q

What happens in the clonic phase of grand mal?

A

rhythmic extremity jerking; slows before stopping

76
Q

what are some of the other things that happen in grand mal?

A

drooling
foaming at the mouth
incontinence
biting of tongue/bleeding

77
Q

Describe the postictal period in grand mal?

A

lasts from minutes to hours; confusion and lethargy, may be agitated

78
Q

describe the EEG in grand mal seizures/

A

generalized polyspikes, can be obscured by muscle artifact

79
Q

Describe the EEG in the postictal period of grand mal?

A

background suppression then diffuse slowing

80
Q

what are the causes of seizures in infancy and childhood?

A

prenatal and birth injury
inborn error of metabolism
congenital malformations

81
Q

what are causes of seizures in childhood and adolescence

A

idiopathic/genetic syndrome
CNS infx
trauma

82
Q

what are the causes of seizures in adolescents and young adults?

A

DRUG INTOX AND WITHDRAWAL

head trauma

83
Q

What are the causes of seizure in older adults?

A

stroke
brain tumor
ACUTE METABOLIC DISTURBANCE
neurodegenerative

84
Q

what should be done in the initial seizure workup?

A
  1. determine if it actually was a seizure
  2. search for evidence of partial onset
  3. search for evidence of underlying CNS dysfunction
  4. look for systemic or metabolic disorders
  5. classify seizure
  6. determine studies
  7. determine drugs
85
Q

What blood tests should be ordered after the first seizure?

A 
CBC
electrolytes
glucose
calcium
magnesium
phosphate
hepatic and renal function
blood/urine drug screen
EEG
CT or **MR*** brain scan
86
Q

When should you do an LP after a seizure?

A

if you suspect meningitis, encephalitis and potential for brain herniation is excluded

87
Q

what postictal findings suggest lateralization?

A

weakness, aphasia, or sensory dysfunction

88
Q

What is an important sign of upper-motor involvement postictally?

A

babinski sign

89
Q

Signs that are non-transient may indicate a preexisting structural issue like….

A

tumor, or a stroke

90
Q

when would you use a CT over an MRI in initial assessment of a seizure?

A

if you suspect an acute process (intracerebral hemorrhage)

91
Q

Can CT rule out small tumors, vascular malformations, hippocampal atrophy, and cortical dsyplasia?

A

no, you need an MRI

92
Q

what are some seizure precipitants?

A 
  Metabolic and Electrolyte Imbalance
  Stimulant/other proconvulsant intoxication
  Sedative or ethanol withdrawal
  Sleep deprivation
  Antiepileptic medication reduction or inadequate
	AED treatment
  Hormonal variations
  Stress
  Fever or systemic infection
  Concussion and/or closed head injury
93
Q

what particular metabolic disturbances can lead to a seizure/

A 
low blood glucose
high blood glucose w/ hyperosmolar state
low sodium
low calcium
low magnesum
94
Q

Which antidepressants can lower your seizure threshold?

A

bupropion

Tricyclics

95
Q

what drugs can lower your seizure threshold?

A 
bupropion
TCAs
Neuroleptics
Phenothiazines
Clozapine
Theophylline
Isoniazid
PCN
Cyclosporins
Meperidine
96
Q

what percent of uprovoked seizures will recur in 5 years?

97
Q

relapse rate may be reduced by the use of….

98
Q

What things increase the risk of relapse rate?

A

abnl imaging
abnl neuro exam
abnl EEG
FHx

99
Q

does treatment with an AED eliminate the risk of a recurrence of seizure?

A

no but it does decrease it by 50%

100
Q

what is the determining factor in choosing an AED for partial epilepsy?

A

side effects profile and patient concerns

101
Q

What is the determining factor in choosing an AED for generalized epilepsy

A

predominant seizure type

and also SE profile and patient chocie

102
Q

what are the broad spectrum AEDs?

A 
Valproate
Felbamate
Lamotrigine
Topiramate
Zonisamide
Levetiracetam
Rufinamide
Vigabatrin
103
Q

What are the AEDs for partial onset seizures?

A 
Phenytoin
Carbamazepine
Oxcarbazepine
Gabapentin
pregabalin
Tiagabine
Lacosamide
104
Q

What is the only drug you can use for absence seizures?

A

Ethosuximide

105
Q

Which drugs have the best FDA evidence for partial seizure monotherapy?

A

Carbamazepine
Oxcarbazepine
Phenytoin
Topiramate

106
Q

Which drugs have similar efficacy to first choice drugs but are better tolerated for partial seizure monotherapy?

A

Lamotrigine
Gabapentin
levetiracetam

107
Q

What are non-firstline drugs that have been shown to be effective in partial seizure monotherapy?

A

Valproate
phenobarbitol
felbamate
lacosamide

108
Q

Which drugs have limited data but are commonly used in monotherapy for partial seizures?

A

Zonisamide

Pregabalin

109
Q

What are the two best drugs for monotherapy of generalized onset tonic-clonic seizures?

A

Valproate

Topiramate

110
Q

Phenytoin and carbamazepine may exacerbate which two types of seizures?

A

absence and myoclonic seizures

111
Q

Lamotrigine may exacerbate which type of seizure?

A

myloclonic sz of symptomatic generalized epilepsy

112
Q

what drug is used in photosensitive epilepsy?

113
Q

Clonazepam and phenobarbitol are useful in generalized seizures but have what greater SEs?

A

sedation and behavioral effects

114
Q

which two drugs can be used for absence seizures?

A

ethosuximide

valproate

115
Q

Which three drugs have the best evidence of working for myoclonic seizures?

A

Valproate
levetiracetam (FDA indicated as adjunctive Tx)
Clonazepam (FDA indicated)

116
Q

What drugs can you use to treat Lennox-Gastaut?

A 
Topiramate
***Felbamate***
Clonazepam
Lamotrigine
Rufinimide
Valproate
117
Q

When converting to monotherapy what two things should you do?

A

eliminate sedative drugs first and withdraw the AEDs slowly over several months

118
Q

Which AEDs may INDUCE the metabolism of other drugs?

A

Carbamazepine
phenytoin
phenobarbitol
primidone

119
Q

Which AEDs may INHIBIT the metabolism of other drugs?

A

valproate

felbamate

120
Q

Which AEDs are protein bound?

A

Valproate, phenytoin tiagabine
Carbamazepine, Oxcarbamazepine
Topiramate

121
Q

which drug classes may alter metabolism and protein binding of AEDs?

A

Abx
chemotherapy
antidepressants
ASA, warfarin, and phenothiazines (protein bound)

122
Q

when is monitoring serum concn of AEDs useful?

A 
when the patient is taking other high protien bound drugs, or in pts with renal disease or hypoalbuminemia
OR:
optimizing therapy
assessing compliance
monitoring during pregnancy
testing drug-drug intrxnsvs
123
Q

Which AEDs decrease the effect of oral contraceptives?

A 
Phenytoin
carbamazepine
Phenobarbitol
Topiramate
Oxcarbazepine
Felbamate
so that means you give you high dose birth control pills
124
Q

The pill can decrease which AED levels by 50%

A

lamotrigine; it can be toxic during the placebo week

125
Q

lamotrigine can decrease the level of which hormone?

A

progesterone; need shorter intervals between Depo shots

126
Q

T/F: therapeutic and toxic ranges on AEDs are the same for all patients

A

false; they are set by the patients themselves!!

127
Q

T/F: SE of AEDs are not dose related

A

false; usually dose related

128
Q

What SE are common to all AEDs?

A

dizziness, fatigue, ataxia, diplopia

129
Q

Which drug causes irritability?

A

levetiracetam

130
Q

which drug causes word finding problems?

A

topiramate

131
Q

which AEDs cause wt. loss and anorexia?

A

topiramate
zonisamide
felbamate

132
Q

which AEDs cause weight gain?

A

valproate (also causes PCOS)

carbamazepine, gabapentin, pregaballin

133
Q

Which drugs give you renal stones?

A

topiramate

zonisamide

134
Q

Which drugs cause anhydrosis and heat stroke?

A

topiramate

135
Q

Which drugs cause acute closed-angle glaucoma?

A

topiramate

136
Q

Which drugs cause hyponatremia?

A

carbamazepine

oxcarbazepine

137
Q

which drugs cause aplastic anemia?

A

felbamate
zonisamide
valproate
carbamazepine

138
Q

Which drugs cause hepatic failure?

A

valproate
felbamate
lamotrigine
phenobarbitol

139
Q

which drug causes peripheral vision loss

A

vigabatrin

140
Q

which drug causes rash?

A

phenytoin
lamotrigine
zonisamide
carbamazepine

141
Q

What are the predictors of developing a rash with AED use?

A

occurrence of another AED-rash

more common in asian populations

142
Q

Stevens-Johnson syndrome and toxic Epidermal necrolysis (TENS) are characterized by….

A

blisters and erosions of the skin, particularly palms and soles and mucous membraines
fever and malaise

143
Q

Which drugs have the highest risk of SJS or TENS?

A

rapid titration of lamotrigine, esepcially in combo with valproate

144
Q

which comorbidities are worsened by AEDs?

A

Osteoporosis
Migraine
Depression

145
Q

osteoporosis is worsened by AED enzyme (inducers/inhibitors)

A

enzyme inducers

146
Q

Which drugs worsen osteoporosis?

A

Phenytoin
Phenobarbitol
Primidone

147
Q

Which drugs should you put your pts on if they have migraine?

A

topiramate

valproate

148
Q

Which AED worsens depression?

A

levetiracetam

149
Q

Which AEDs help depression?

A

lamotrigine
gabapentin
pregabaline
vagus nerve stimulator

150
Q

T/F: you can have interictal depression

A

true; along with prodromal and peri-ictal

151
Q

how many times higher is the the suicide rate in pts with depression and epilepsy?

152
Q

T/F: AEDs slightly increase the risk of suicide

153
Q

how long must you be seizure free to discontinue AED use?

A

> 2 years; implies 60% chance of successful withdrawal from AED

154
Q

What are factors favoring discontinuing AEDS?

A
  1. control easy on low dose monotherapy
  2. no previous unsuccessful attempts
  3. nomral neuro exam and EEG
  4. pimary generalized seizures exccpet JME
  5. “Benign” syndrome with centrotemporal spikes
155
Q

Is mandatory physician reporting to the DMV required in NV?

A

yes (1 of 6 states)

156
Q

How many exceptions are there to the mandatory license loss in NV w/ seizures?

157
Q

What are the 5 exceptions to loss of license?

A

Breakthru seizure d/t MD-directed med change
Isolated seizure w/ unlikely additional seizures
Seizure related to temporary illness
Est nocturnal seizures
Est simple partial seizures (w/ no risk of generalization)

158
Q

when can pts reapply for a driver’s license?

A

after 3 months being seizure free

159
Q

what are the lifestyle changes that help avoid seizures?

A

sleep
avoid alcohol and stimulants
avoid known precipitants
stress reduction

160
Q

What is the efficacy of a ketogenic diet as an AED?

A

50% with a >50% seizure reduction; 30% with >90%; ketosis is anti-seziure

161
Q

What are the SE of a ketogenic diet/

A

kidney stones
wt. loss
acidosis
dyslipidemia

162
Q

What is “status epilepticus”?

A

10+ minutes of continuous seizure activity of any type
OR
2+ sequential seizures w/o full recovery btwn seizures

163
Q

How long do most seizures last?

A

less than 5 min

164
Q

Is status epilepticus an emergency?

165
Q

what are some adverse consequences of status epilepticus?

A 
hypoxia
hypotension
acidosis
hyperthermia
rhabdomyolysis
neuronal injury
166
Q

what is the goal w/ status epilepticus?

A

STOP THE SEIZURES

167
Q

what is “kindling” wrt status epilepticus?

A

abnormal seizing cells convince their neighbors to start seizing > causes more damage & makes seizure worse

168
Q

T/f: vagus nerve stimulator has positive effects in mood and can allow AED reduction

169
Q

What are the components of the Atkins diet?

A

10g/day of carbs, fats encouraged

No protein, calorie, or fluid restriction

170
Q

how many carbs a day do you get with low glycemic index treatment?

A

40-60g/day of low glycemic index carbs

portions are controlled

171
Q

What are the criteria in which a pt is eligible for surgery?

A

Unacceptable seizure control despite max tolerated doses of 2-3 drugs

172
Q

Which vagus nerve is stimulated?

A

left nerve

173
Q

what do you do if your pt has been in status for 10-20 min?

A

fosphenytoin IV w/ BP & EKG monitoring (but you can skip this step, or load fosphenytoin w/ the next step)

174
Q

T/f: vagus nerve stimulator has positive effects in mood and can allow AED reduction

175
Q

What are the 7 things you need to do in the first 5 minutes of SE TX?

A 
ABCs
Give O2
IV access
EKG monitoring
Glucose
Draw blood
Tox screen
176
Q

What drug should you give a SE pt if alcohol withdrawal is suspected?

A

Thiamine 100mg IV

177
Q

What drug should you give SE pts if you do NOT know their glucose level?

A

D50 50ml IV

178
Q

What drug should you give a SE pt (generally)?

A

Lorazepam
4 mg IV over 2 min

if still seizing, repeat in 5 mins

179
Q

what can you give a pt in status if you do NOT have IV access?

A

diazepam (rectal)

midazolam (nasal, bucal, or IM)

180
Q

what do you do if your pt has been in status for 10-20 min?

A

fosphenytoin IV w/ BP & EKG monitoring (but you can skip this step, or load fosphenytoin w/ the next step)

181
Q

if your pt has been seizing for 10-60 min, what are your 4 options?

A

continuous IV midazolam
continuous IV propofol
IV valproate
IV phenobarbital

***Intubate for all except valproate

182
Q

what is your last resort for a pt in status epilepticus?

A

attempt to flatline the EEG w/ petrobarbital

183
Q

What percent of pts with a vagus nerve stimulator have a 50% reduction in seizures?

184
Q

vagus nerve stimulator is FDA approved for what types of seizures?

A

refractory partial onset and refractory depression

185
Q

What is status epilepticus?

A

more than 10 minutes of continual seizure; or two or more sequential seizures without full recovery between them

186
Q

what are the consequences of status eplepticus

A 
hypoxia
hypotension
acidosis
hyperthermia
rhabdomyloysis
neuronal injury
187
Q

what should you test for on blood draw in SE?

A

chem-7, magnesium, calcium, phosphate, CBC, LFT AED level, ABG, troponin
tox screen in urine and blood

Block 8 Week 5 Colt (12 decks)

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