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meidicine. first seizure.(dr.muhamad tahir)
 

meidicine. first seizure.(dr.muhamad tahir)

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    meidicine. first seizure.(dr.muhamad tahir) meidicine. first seizure.(dr.muhamad tahir) Presentation Transcript

    • The Management of the First Seizure Dr Mohammed Tahir١٢/١٨/٢ Dr Laura Martin (with a little bit of help 1 from Tony Holley)
    • Aims• To have an understanding of the common causes of a first seizure presenting to the Emergency Department• To have an understanding of the basic management of the first seizure• To have some basic rules for seizure management١٢/١٨/٢ Dr Laura Martin (with a little bit of help 2 from Tony Holley)
    • Definition of SeizureAn episode of abnormal neurological functioning caused by abnormal discharge of neurons! ١٢/١٨/٢ Dr Laura Martin (with a little bit of help 3 from Tony Holley)
    • Classification of Seizures• Generalised - loss of consciousness• Partial - no loss of consciousness• Unclassified١٢/١٨/٢ Dr Laura Martin (with a little bit of help 4 from Tony Holley)
    • Classification of Seizures Generalised Partial• Absence Simple Partial • Motor• Tonic Clonic • Sensory• Myoclonic • Autonomic• Clonic Complex Partial• Tonic • With psychic, cognitive or affective symptoms• Atonic • With automatisms Partial seizures with secondary generalisation١٢/١٨/٢ Dr Laura Martin (with a little bit of help 5 from Tony Holley)
    • Classification of Seizures by Etiology• Acute Symptomatic seizures• Remote Symptomatic seizures• Idiopathic١٢/١٨/٢ Dr Laura Martin (with a little bit of help 6 from Tony Holley)
    • Acute Symptomatic seizuresCNS infections• Meningitis Neoplasms• Encephalitis• Abscess • BenignVascular disease • Malignant - Primary,• CVA Secondary• Vasculitis MetabolicTrauma • Electrolyte disturbancesHypertensive • HypoglycaemiaEclampsia • Hypoxia • Renal Failure ١٢/١٨/٢ Dr Laura Martin (with a little bit of help 7 from Tony Holley)
    • Acute Symptomatic seizures- Toxin DrugsTricyclic antidepressants CocaineAntidepressants AmphetaminesTheophylline LignocaineWithdrawal - ETOH, Anti -psychoticsbenzo’s AntihistaminesAnticholinergics IsoniazidOrganophosphates١٢/١٨/٢ Dr Laura Martin (with a little bit of help 8 from Tony Holley)
    • Remote Symptomatic Seizures• Previous head injury• Previous CVA• Congenital CNS disorders• Previous hypoxic injury• Previous CNS infections• Degenerative diseases١٢/١٨/٢ Dr Laura Martin (with a little bit of help 9 from Tony Holley)
    • Incidence & Epidemiology• 5% of the population have a seizure some time in their life• Bimodal frequency• adult 1st generalised seizure accounts for 1% ED visits١٢/١٨/٢ Dr Laura Martin (with a little bit of help 10 from Tony Holley)
    • Causes of seizures presenting to Emergency DepartmentsCause Sempere et al 1992 Henneman et al 1994Idiopathic 27.6% 44.0%Infarction 23.5% 11.0%Cerebral Cystercercosis - 12.0%ETOH 11.2% -CNS infections 9.2% 10%CNS tumour 8.2% 7.0%Vascular Malformation 6.1% -Trauma 4.1% 4.0%Drug toxicity 3.1% -Hyponaetraemia 2.0% 2.0%Systemic Infection - 2.0%Other 5.0% 9.0%١٢/١٨/٢ Dr Laura Martin (with a little bit of help 11 from Tony Holley)
    • Causes of seizures by ageCause Age < 45 years Age > 45 yearsIdiopathic 45% 15.5%Infarction 2.5% 37.9%ETOH 15% 8.6%CNS infections 17.5% 3.4%CNS tumours 2.5% 12%Vascular Malformation 7.5% 5.2%Trauma 7.5% 1.7%Drug toxicity 0% 5.2%Other 2.5% 10.2% Sempere et al 1992١٢/١٨/٢ Dr Laura Martin (with a little bit of help 12 from Tony Holley)
    • Causes of seizures by age - acutesymptomatic seizures• 6/12 to 5 years -Febrile convulsions• Young adults -Trauma 26% -Drug withdrawal 20%• Elderly - CVA 44% Annegers et al 1995١٢/١٨/٢ Dr Laura Martin (with a little bit of help 13 from Tony Holley)
    • Presentation to the Emergency Department Differentiated Undifferentiated• Febrile convulsion • Cardiac Arrhythmias• Idiopathic epilepsy • Vasovagal Episode• Acute symptomatic • Cardiac - Structural seizures • Blood loss• Remote Symptomatic • Postural Hypotension seizures • Sepsis • Psychogenic • etc١٢/١٨/٢ Dr Laura Martin (with a little bit of help 14 from Tony Holley)
    • Presentation to the Emergency Department• Has the patient had a seizure?• What kind of seizure was it?• Was there a focal component?• Was this the first seizure?• Is there a family history of seizure disorder?• Why did the seizure occur?١٢/١٨/٢ Dr Laura Martin (with a little bit of help 15 from Tony Holley)
    • Other Important History• Systemic illness• drug use/abuse• pregnancy• mental retardation• head injury• unexplained bruises/tongue biting• nocturnal enuresis• precipitants١٢/١٨/٢ Dr Laura Martin (with a little bit of help 16 from Tony Holley)
    • Management• Historical documentation of the seizure• Physical examination• Investigations• Cessation of seizures• Observation• Disposal• Advice• Seizure Prophylaxis• Follow up١٢/١٨/٢ Dr Laura Martin (with a little bit of help 17 from Tony Holley)
    • Investigations١٢/١٨/٢ Dr Laura Martin (with a little bit of help 18 from Tony Holley)
    • Rule Always do a glucose on any one who is having a seizure or has had a seizure!١٢/١٨/٢ Dr Laura Martin (with a little bit of help from Tony Holley) 19
    • Scenario 1• 17 year old girl• Post first witnessed tonic clonic seizure• Been out to a party the night before• Uncle has epilepsy• Now well, GCS 15, Vital signs normal• Neurological exam normal١٢/١٨/٢ Dr Laura Martin (with a little bit of help 20 from Tony Holley)
    • Investigations• Glucose• Sodium• Calcium• Consider urine and pregnancy test• CT [ MRI ] & EEG as outpatient١٢/١٨/٢ Dr Laura Martin (with a little bit of help 21 from Tony Holley)
    • Post first seizure advice• Management of a seizure at home• Safe activities• Driving• Who should know?• Have I got epilepsy?• Not life threatening• Exacerbating factors• Follow up١٢/١٨/٢ Dr Laura Martin (with a little bit of help 22 from Tony Holley)
    • Seizure recurrence• Most common within the first 6 months• More than 50% of those who have recurrence will occur within 6 months• Rate varies from 36 -77%١٢/١٨/٢ Dr Laura Martin (with a little bit of help 23 from Tony Holley)
    • Seizure recurrence increased if• Symptomatic Seizure• History of epilepsy in a sibling• Todd’s paralysis• EEG abnormalities• 2 seizures - 80-90%١٢/١٨/٢ Dr Laura Martin (with a little bit of help 24 from Tony Holley)
    • RULE Seizure prophylaxis for all firstsymptomatic seizures١٢/١٨/٢ Dr Laura Martin (with a little bit of help 25 from Tony Holley)
    • Scenario 2• 50 yr old woman• Post tonic clonic seizure• Husband said twitching started in her R arm, then progress to LOC.• History of recent headaches.• Now well, GCS 15, appears neurologically intact• Vital signs normal١٢/١٨/٢ Dr Laura Martin (with a little bit of help 26 from Tony Holley)
    • RULE ALWAYS LOOK IN THE FUNDI١٢/١٨/٢ Dr Laura Martin (with a little bit of help 27 from Tony Holley)
    • RULE First Focal Seizure = CT scan!!!!!!١٢/١٨/٢ Dr Laura Martin (with a little bit of help 28 from Tony Holley)
    • Scenario 3• 50 yr old woman• Post generalised seizure• Previously well, no seizures in the past• Recent headache for 24 hours, unwell & fever• Now GCS 13, Temp 39.8• Confused, unco-operative 30 minutes post seizure• Moving all limbs.١٢/١٨/٢ Dr Laura Martin (with a little bit of help 29 from Tony Holley)
    • Who to CT?• Focal seizures• trauma• anticoagulants• alcoholics• immunosuppressed• fever,stiff neck,persistent headache• focal neurology١٢/١٨/٢ Dr Laura Martin (with a little bit of help 30 from Tony Holley)
    • RULE Do not LP a patientwho has a decreasedGlascow coma score!! Treat first, CT & ask questions later!!١٢/١٨/٢ Dr Laura Martin (with a little bit of help 31 from Tony Holley)
    • RULE A GCS < 13 is a relative contraindication to LP even after a١٢/١٨/٢ normal CT!! Dr Laura Martin (with a little bit of help from Tony Holley) 32
    • Scenario 4• A 75 yr old man• Previous hypertension• Post tonic clonic seizure• Now GCS 15 but right arm weakness١٢/١٨/٢ Dr Laura Martin (with a little bit of help 33 from Tony Holley)
    • RULEFocal neurology = CT scanFocal neurology does not = LP١٢/١٨/٢ Dr Laura Martin (with a little bit of help 34 from Tony Holley)
    • Scenario 5• 18 yr old man• Rugby injury with LOC, scalp laceration• Initially in ED GCS 15, vomited twice and complaining of a headache• Has tonic clonic seizure in ED. Self resolved• Now GCS 12 - 2 minutes post seizure١٢/١٨/٢ Dr Laura Martin (with a little bit of help 35 from Tony Holley)
    • RULE Trauma & Seizure = CT scan!!١٢/١٨/٢ Dr Laura Martin (with a little bit of help 36 from Tony Holley)
    • Status Epilepticus• Continuous or repetitive seizures without time for recovery• neuronal injury can occur in less than 30min• may be subtle١٢/١٨/٢ Dr Laura Martin (with a little bit of help 37 from Tony Holley)
    • RULE• BEWARE THE INTER-ICTAL PATIENT١٢/١٨/٢ Dr Laura Martin (with a little bit of help 38 from Tony Holley)
    • Treatment of Status Epilepticus• All patients who still fitting on arrival to ED• fitting for more than 10min• LONGER THE DELAY HARDER TO CONTROL١٢/١٨/٢ Dr Laura Martin (with a little bit of help 39 from Tony Holley)
    • 0-5 minutes• Confirm diagnosis• Oxygen• Airway & Breathing [ Consider ETT ]• Vital signs• IV access• Glucose check• Oximetry• Lab١٢/١٨/٢ Dr Laura Martin (with a little bit of help 40 from Tony Holley)
    • 5-10 minutes• If hypoglycaemic treat• Adults 100 mg thiamine followed by 50 mls 50% glucose• Children 2 mls/kg 25%١٢/١٨/٢ Dr Laura Martin (with a little bit of help 41 from Tony Holley)
    • 10-20 minutes•0.1 mg/kg lorazepam at 2mg/min up to 4 mg total or•0.2 mg/kg diazepam at 5mg/min up to 20mg/min Diazepam must be followed by a loading dose of phenytoin١٢/١٨/٢ Dr Laura Martin (with a little bit of help 42 from Tony Holley)
    • Difficult access?• IM midazolam 10mg• PR diazepam 0.5 mg/kg• PR lorazepam 0.1mg/kg١٢/١٨/٢ Dr Laura Martin (with a little bit of help 43 from Tony Holley)
    • 20+ minutes• Load with phenytoin 20 mg/kg no faster than 50 mg/min in adults and 1mg/kg/min in children• IV fluids must be N Saline١٢/١٨/٢ Dr Laura Martin (with a little bit of help 44 from Tony Holley)
    • If Status continues• 1. Additional phenytoin 5 mg/kg up to a total of 30 mg/kg• 2. Midazolam load 0.2 mg/kg infusion• 3. Phenobarbitone 20mg/kg at max 100mg/min• 4. Proprofol load with 0.2mg/kg then infusion• Expect apnea• Intubation will be required - rapid sequence induction with thiopentone and suxamethonium١٢/١٨/٢ Dr Laura Martin (with a little bit of help 45 from Tony Holley)
    • Admission criteria for a first seizure• Acute Symptomatic • Status epilepticus or Seizure requiring prolonged seizure. ongoing treatment & • Recurrent seizures investigation • Social Situation• Febrile seizure where underlying cause needs treatment or fever does not settle• Focal seizure١٢/١٨/٢ Dr Laura Martin (with a little bit of help 48 from Tony Holley)
    • Conclusion No one seizure is the same The clinician must always think of the underlying cause & investigate & treat appropriately١٢/١٨/٢ Dr Laura Martin (with a little bit of help 49 from Tony Holley)
    • References• Em Clinics N America Feb 1999 17;1• Emergency medicine reports Vol 18;14 1999• Neurology Nov 1999 S4• Lancet July 2000 Vol 356١٢/١٨/٢ Dr Laura Martin (with a little bit of help 50 from Tony Holley)