Tutorial #34: Adult Seizures Flashcards
What is the definition of status epilepticus?
Seizure activity that is >= 5 minutes, OR
two or more seizures without regaining consciousness between seizures
Refractory status epilepticus is persistent seizure activity despite the IV administration of adequate amounts of two antiepileptic agents
Generalized seizures can be characterized as… (2)
Absence: lack of awareness, but no significant motor activity
Tonic clonic (GTC): rigidity (tonic phase) then symmetric rhythmic jerking (clinic phase)
What is the definition of a focal seizure?
Seizure activity due to electrical discharges beginning in a localized region of the cerebral cortex.
More likely to be due to a localized structural lesion in the brain.
ex:
left arm tonic movement = right motor cortex lesion
visual symptoms = occipital region legion
Focal seizures can be characterized as?
Focal seizures with retained awareness
Focal seizures with awareness impaired
What are 4 clinical features that can help you distinguish a seizure from other non-seizure attacks (ex. syncope)
Seizures:
1. have abrupt onset and termination in most cases
2. cause a lack of recall of the event (except focal seizures with retained awareness aka. simple partial seizures)
3. Purposeless movement or behaviours during the attack
4. most seizures are followed by a postictal period.
What are 3 common diagnoses that often get mistaken for seizures (ie. seizure mimics)
- syncope
- Psychogenic nonepileptic seizures (pseudoseizures)
- migraine headaches
When is a CT scan of the head indicated for seizure?
- First presentation for seizure
- Change in seizure pattern
- Red flag on history/exam or motor deficit
When is a lumbar puncture indicated in the setting of an acute seizure?
- The patient is febrile
- patient is immunocompromised
- suspected subarachnoid hemorrage but non-contrast CT is normal.
Once a patient has established status epilepticus, what should you administer in general? (x2)
- An IV benzodiazepine AND
- And IV second line anti epileptic medication (phenytoin, keppra, etc)
Options for benzodiazepines
- IV lorazepam
- IV diazepam
Options for anti-seizure medication
- IV fosphenytoin
- IV phenytoin
- IV levetiracetam
What is the target time to terminate status epilepticus?
< 5-10 minutes
if a patient is in refractory status epilepticus, what is the goal of their treatment?
Chemical sedation and intubation for airway protection
therefore these patients need to be intubated, and placed in the ICU.
What are the 3 medication options for refractory status epilepticus
- IV midazolam OR
- IV propofol OR ketamine OR
- IV phenobarbital
What is the rule in/out test for hypoglycemia as an etiology for seizures, and what is the treatment?
Ppoint-of-care glucose testing. Symptoms usually start at a blood glucose < 3. Coma can occur at blood glucose < 2
Treatment: Give IV glucose
When evaluating a patient with seizures, what are the 4 questions you should ask yourself at the beginning?
- Was it a seizure? (could it have been a seizure mimic)
- Is there an underlying cause for the seizure (consider the DIMS mneumonic)
- Is there another precipitant for the seizure? (ex. patient is non-compliant with anti-seizure medication
- Is there a treatment to prevent another seizure? (ex. give glucose if patient is hypoglycemic)
What serum Na can seizures occur? (Both hypo and hyper)
Na < 115-120
Na > 158
In terms of duration how can you differentiate between epileptic seizures, and psychogenic nonepileptic seizures?
PNES usually last longer than 2 minutes
What eye activity helps you differentiate epileptic and psychogenic non-epileptic seizures?
In PNES, eyes are often forced closed. In epileptic seizures, eyes are usually open
What are observed movements help differentiate PNES from GTC seizure?
GTC: Stereotyped, synchronized movements that typically progress/crescendo.
PNES: Variable movements, forward pelvic thrusting, rolling side to side, opisthotonus
Wax and wane pattern
