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Clinical series.seizure

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    Clinical series.seizure Clinical series.seizure Presentation Transcript

    • Amal Al Shibli SQUH ED Seizure Amal Al shibli
    • Presentation Outline
      • Pathophysiology
      • Types
      • ED approach to seizure
      • ED management
      • Disposition
      • Conclusion
    • Pathophysiology
      • Which of the following statements regarding seizures is true?
      • The clinical seizure activity typically reflects the brain focus of initiation
      • To produce generalized seizures, a stimulus must be applied to one hemisphere
      • Regarding seizure activity, acetylcholine is inhibitory
      • Regarding seizure activity, -aminobutyric acid (GABA) is excitatory
      • During a seizure, prompt loss of consciousness implies a cortical focus
    • Seizure primary (epileptic) secondary (reactive) focal ( partial ) generalized convulsive nonconvulsive simple complex partial with 2 nd generalization
    • Classification of Seizures in a General Adult Population 9 Unclassified 12 Mixed partial 27 Secondarily generalized 11 Complex partial 3 Simple partial   Partial 2–3 Others <1 Myoclonic 1 Absence 35 Tonic-clonic   Generalized PERCENTAGE SEIZURE TYPE
    • Consciousness Vs Cognition
      • cognition is defined as involving at least two of the 5 features :
        • Perception
        • Attention
        • Emotion
        • Memory
        • executive function
      • Which of the following statements regarding partial seizures is true?
      • Automatisms such as lip smacking, swallowing, or verbal phrases are characteristic of simple partial seizures
      • Simple partial seizures are often associated with an aura such as a specific smell, taste, or emotional feeling
      • Dysphasia, a sense of déjà vu, or feeling of unwarranted fear characterize a complex partial seizure
      • Amnesia is a consistent finding in complex partial seizures
      • A postictal state is uncommon after complex partial seizures
      • Which of the following may help differentiate absence nonconvulsive generalized seizures from complex partial seizures ?
      • Sudden onset
      • A dissociative state
      • Lack of an aura or postictal state
      • Typical onset in childhood
      • The presence of automatisms
    • All true regarding primary seizure except :
      • All classes may recur sporadically, randomly, or predictably
      • Cyclic recurrence has been reported with awakening, sleep deprivation, emotional or physical stress, alcohol, and menses, among other factors
      • the most common of which is visual stimulation in the form of flashing lights, such as strobe lights, television, and video games
      • Seizures also can be caused by auditory, gustatory, tactile or startle triggers that are specific to the affected person
      • The most common cause of recurrent primary seizures is sub-therapeutic antiepileptic dose
        • a continuous seizure lasting > 5 minutes,
        • OR
        • > 2 discrete seizures without intervening recovery of consciousness
    • ETIOLOGY OF STATUS EPILEPTICUS Intoxication Withdrawal Syndromes Metabolic Disturbances Infectious Processes CNS Lesions
      • CNS abscess
      • Encephalitis
      • Meningitis
      • Alcohol
      • Antiepileptic drugs
      • Baclofen
      • Barbiturates
      • Benzodiazepams
      • Flumazenil
      • INH
      • Lead,Lidocaine,Lithium
      • Metronidazole
      • Theophylline
      • TCA
      • Hepatic encephalopathy
      • ↓ or ↑ glusose
      • Ureamia
      • ↓ Na +
      • The most common cause of status epilepticus is discontinuation of anticonvulsant medication
      • This situation may be compounded by barbiturate withdrawal when phenobarbital therapy is abruptly withdrawn
      • Patients may present for the first time with a primary seizure disorder in status
    • Seizure primary (epileptic) secondary (reactive) focal ( partial ) generalized convulsive nonconvulsive simple complex partial with 2 nd generalization
    • secondary (reactive) Seizure
      • Metabolic Derangements
      • Infectious Diseases
      • Drugs and Toxins
      • Trauma
      • Malignancy or Vasculitis
      • Strokes, Arteriovenous Malformations, and Migraines
      • Degenerative Disease of the Central Nervous System
      • Gestational Seizures
      • Psychogenic Nonepileptic Seizures
    • Metabolic Derangements
      • A 33-year-old woman presents in status epilepticus. Her past history is remarkable for diabetes, hypertension, and chronic renal insufficiency. Her current medications are NPH insulin, enalapril, and furosemide. Urgent laboratory analysis reveals glucose 41 mg/dL, Na 124 mEq/L, K 54 mEq/L, Cl- 91 mEq/L, HCO3- 17 mEq/L, BUN 48 mg/dL, calcium 76 mg/dL, creatinine 48 mg/dL, and albumin 28 g/dL. What is the most likely explanation for her seizure activity?
        • Hypoglycemia
        • Hyponatremia
        • Hypocalcemia
        • Hyperkalemia
        • Uremia
      • Which of the following endocrine derangements may cause status epilepticus?
      • Cushing’s syndrome
      • Thyrotoxicosis
      • Hyperparathyroidism
      • Growth hormone excess
      • Androgen excess
      • A 43-year-old man presents in status epilepticus. He had attempted to complete a marathon but complained of lethargy and headaches at mile 18 and then collapsed with generalized seizures at mile 20. He has no past history and takes no medications. Urgent laboratory analysis reveals glucose 200 mg/dL, sodium 117 mEq/L, potassium 54 mEq/L, chloride 89 mEq/L, and HCO3- 14 mEq/L. What agent is most likely to rapidly terminate his seizures?
        • Lorazepam
        • Phenytoin
        • Insulin
        • Hypertonic saline
        • Sodium bicarbonate
    • Glucose
      • Hypoglycemia is a common metabolic cause of reactive seizures
      • Ictal activity can occur when the plasma glucose level is <45 mg/dL ( 2.5 mmol/L) , although some patients may manifest neurologic disturbances even at higher levels
      • Patients at the extremes of age are particularly susceptible to glucose stress during acute illness
      • Hypoglycemia also may result from insulin reaction, a deliberate insulin or hypoglycemic agent overdose, alcoholism, poor nutrition, and sepsis
      • Hypoglycemic seizures respond to glucose therapy; anticonvulsants are unnecessary
    • Na+
      • Disorders of sodium—the primary cation in the extracellular fluid compartment & the primary determinant of serum osmolarity—are most common
      • Hyponatremia is the most frequently identified electrolyte disorder in hospitalized patients, and sodium levels less than 120 mEq/L often are associated with seizures
      • The rate at which the sodium level decreases, and not the absolute magnitude of the decrease, determines the risk for neurologic manifestation  Rx slowly
      • If seizures are persistent, administration of hypertonic (3%) saline
    • Ca+² & Mg+²
      • significant ↓Ca (7.5 mEq/L) is associated seizure
      • ↓ Ca may result from hypoparathyroidism, renal failure, or acute pancreatitis
      • ↓ Ca typically is associated with ↓Mg, which also can precipitate seizures, particularly at serum levels < 1 mEq/L
      • ↓ Mg is seen most often as a result of poor nutrition, especially in alcoholic pts
      • Pts with significant ↓Ca or ↓Mg should be treated empirically for both disorders
      • Seizures may complicate the course and treatment of renal failure
      • Ictal activity occasionally
        • complicates uremic encephalopathy, is more common in conjunction with acute fluid and electrolyte shifts during dialysis ( dialysis disequilibrium syndrome )
        • can occur as a complication of immunosuppressive therapy after renal transplantation
      Renal Failure
    • Infectious Diseases
      • Seizures can occur as a result of the acute inflammatory response or as sequelae to bacterial or viral meningitis
      • During the acute course of their illness, up to 40% of patients with meningitis will have at least one seizure; this is more common at the extremes of age but is rarely associated with residual epilepsy
      • By contrast, seizures occur in up to 50% of patients with a brain abscess , and epilepsy develops in 40% of the survivors
      • Viral meningoencephalitides, the most common of which are caused by the herpes simplex virus, also are associated with seizures
      • Primary HIV disease of the CNS, its attendant infectious and mass lesion complications, such as from toxoplasmosis and lymphoma, and the demyelinating infection progressive multifocal leukoencephalopathy constitute a significant cause of generalized and partial seizures
      • Choosing an antiepileptic drug for an HIV-infected patient with seizures should be done in consultation with infectious disease and neurology specialists
    • Drugs & Toxins
      • All are true regarding Ethanol-related seizure except :
      • may occur with acute inebriation but are more common during withdrawal from alcohol
      • Withdrawal seizures typically are generalized, are recurrent, and may begin after 24 hours of cessation of or decrease in alcohol consumption
      • the risk and severity of seizures increase with each episode of withdrawal
      • Alcoholic patients with seizures must be evaluated for other related, concomitant ictogenic problems (e.g., hypoglycemia, electrolyte derangements, head trauma, co-ingestion of other toxins, pregnancy)
      • The preferred treatment for alcohol-associated seizures is with benzodiazepines which substitute for the GABA-enhancing effect of ethanol in the CNS
      • Which of the following matches between the offending epileptogenic agent and the treatment agent or modality is correct?
      • Isoniazid—B12
      • Meperidine—alkalinization
      • Theophylline—dialysis
      • Cocaine—benzodiazepines
      • Lithium—hypertonic saline
      • Seizures may occur :
        • after therapeutic doses of antimicrobials, cardiovascular agents, neuroleptics & sympathomimetics
        • also may result from exposure to plant toxins, insecticides and rodenticides, and hydrocarbons
    • The most common drug-associated and toxin-associated seizures:
        • illicit drugs , such as cocaine, amphetamines & phencyclidine
        • 2. with overdoses of anticholinergic agents, such as TCA and antihistamines
        • 3. as a manifestation of withdrawal from ethyl alcohol and sedative-hypnotics
        • 4. with toxic levels and deliberate overdoses of diverse medications including ASA, theophylline, meperidine, INH, lithium & the anticonvulsants phenytoin and carbamazepine
    • Trauma
      • Which of the following statements regarding post-traumatic seizures is true?
      • Most occur immediately following the traumatic injury
      • The severity of head injury correlates with the likelihood of post-traumatic seizures
      • Adults are more likely to present with status epilepticus
      • Antiepileptic drugs are effective in preventing late post-traumatic seizures
      • Immediate and early post-traumatic seizures are more common in adults
      • Regarding post-traumatic seizures, the false answer is:
      • Early post-traumatic seizures occur within 24 hrs of injury
      • Immediate and early post-traumatic seizures are more common in children than in adults
      • Within the 1 st year after significant head trauma, the incidence of seizures is at least 12 times that in the general population
      • Antiepileptic drugs are recommended for prophylaxis against post-traumatic seizures occurring within the first 7 days after severe brain injury in adults
    • Stroke
      • Which of the following statements regarding seizure and stroke is true?
      • Stroke is the cause of new-onset seizures in 40% to 50% of elderly patients
      • The incidence of epilepsy after stroke is 33%
      • The incidence of seizures with stroke is 50%
      • Seizures that occur acutely with stroke are typically generalized
      • Seizures occurring with a stroke should prompt workup for potential vasculitis
    • Seizures Caused by Strokes
      • Ischemic or hemorrhagic stroke is the cause of new-onset seizures in 40 to 54% of elderly patients
      • The overall incidence of seizures with stroke ranges from 4 to 15%; > 1/2 occur within the 1st week after stroke
      • Seizures that occur acutely with stroke are thought to result from local metabolic alterations in the CNS; these events are transient , and the seizures often are focal and self-limited
      • Seizures that develop later are more likely to be generalized
    • Psychogenic Nonepileptic Seizures
      • All true regarding pseudoseizures except :
      • Psychogenic seizures, or pseudoseizures, are functional events that may be associated with alterations in consciousness, abnormal movements and behaviors, and autonomic changes
      • They are not the result of abnormal CNS electrical activiy.
      • Psychogenic seizures may be primarily motor and mimic convulsive generalized seizures, including refractory status epilepticus, or they may be nonconvulsive and mimic either absence or complex partial seizures
      • Although certain features of convulsive psychogenic seizures may suggest the diagnosis, no clinical criteria are 100% specific; simultaneous video and EEG recordings may be required to confirm the diagnosis
      • The ED evaluation of these patients is easy, because seizures and pseudoseizures usually cannot coexist
      • Characteristics that suggest pseudoseizure rather than true seizure include all of the following except:
      • Alternating clonic extremity movement pattern
      • Occur with audience present & during emotional stress
      • Tongue biting & incontinence is common
      • Pelvic thrusting
      • Side-side head thrashing
      • A 23-year-old woman is brought to the emergency department for a prolonged seizure. By EMS report, the patient has no past medical history and no history of seizures. Paramedics report tonic-clonic activity for approximately 15 minutes, refractory to diazepam 5 mg intravenously in the ambulance. Upon arrival to the emergency department, the patient’s seizure activity abruptly ceases and she lucidly responds to the history and physical examination. She is symptom free. What would be the most appropriate intervention?
        • Confrontation
        • Psychiatric consultation
        • CT scan of the head followed by lumbar puncture
        • Neurology referral for EEG and consultation
        • A trial of oral phenytoin after an intravenous loading dose in the ED
    • Postictal States
    • Neurogenic pulmonary edema
      • Neurogenic pulmonary edema is a relatively common, although often subclinical, complication of any structural CNS insult, including seizure, trauma, and hemorrhage
      • is caused by centrally mediated sympathetic discharge and generalized vasoconstriction, coupled with increased pulmonary capillary membrane permeability
      • After a seizure, neurogenic pulmonary edema can be confused clinically and radiographically with aspiration pneumonia
      • Neurogenic pulmonary edema is managed with ventilatory support, including positive end-expiratory pressure and other aggressive measures to reduce intracranial pressure
    • Todd's paralysis
      • Postictal paralysis, or Todd's paralysis , may follow generalized or complex partial seizures
      • is a focal motor deficit that may persist up to 24 hours
      • Weakness of one extremity or a complete hemiparesis may occur; in the latter case, the patient must be safely restrained to avoid falls caused by a combination of weakness and diminished responsiveness resulting from the postictal state
      • Todd's paralysis is associated with a high likelihood of an underlying structural cause for the seizure
    • Approach to Seizure in ED
    • Q1 . “Was the incident truly a seizure?”
      • focality of onset
      • loss of bowel or bladder control
      • tongue biting
      • Suggestions of an ictal diagnosis:
        • retrograde amnesia
        • loss of continence
        • evidence of tongue biting
        • If blood was drawn soon after a true seizure, it often demonstrates a metabolic acidosis that has resolved by the time a repeat analysis is performed in the ED
      • Abrupt onset : Generalized seizures typically occur without an aura
      • Brief duration : Seizures rarely last longer than 90 to 120 seconds, although bystanders typically overestimate the duration
      • Altered mental status : Present by definition, except for simple partial seizures
      • Purposeless activity: For example, automatisms and undirected tonic-clonic movements
      • Unprovoked : Especially with regard to emotional stimuli; fever in children and substance withdrawal in adults are notable exceptions
      • Postictal state : An acute confusional state that typically occurs with all seizures except simple partial and absence.
      • The most reliable historical feature to distinguish syncope from seizure is :
      • Tonic-clonic movement
      • Incontinence
      • Tongue biting
      • Postictal confusion
      • Premonitory symptoms
      • Q2. “Does this patient have a history of seizures?”
      • History should focus on..
        • intercurrent illness or trauma
        • drug or alcohol use
        • potential adverse drug-drug interactions with anticonvulsants
        • medication compliance
        • a recent change in anticonvulsant dosing regimens
        • a change in ictal pattern or characteristics
      • Supratherapeutic and toxic levels of some anticonvulsants such as phenytoin and carbamazepine , whether attained chronically or after acute overdose, may cause seizures
      • If empiric anticonvulsant therapy is indicated before the serum level is available, only 50% of a full loading dose should be given unless the patient is known reliably not to be taking anticonvulsant medication
    • After Seizure
      • 1. resting vital signs should be evaluated  look for underlying cause if any of the VS abnormal
      • 2. Look for : nuchal rigidity, stigmata of substance abuse, lymphadenopathy suggestive of HIV disease or malignancy, dysmorphic features, or skin lesions
      • 3. focus on potential adverse sequelae of convulsive seizures e.g.
      • complete neurologic examination must be performed
        • persistent focal deficit after a seizure (e.g., Todd's paralysis) often indicates the focal origin of the event but also can be evidence of an underlying stroke
        • patient should be carefully examined for papilledema; elevated intracranial pressure can both cause and result from ictal activity
    • Indications for Emergent Head CT for New-Onset Seizure Patients Persistently altered mental status Focal onset before generalization Age older than 40 years New focal neurologic examination History of anticoagulation Persistent headache Fever Immunocompromise History of malignancy History of acute head trauma Acute intracranial process is suspected
      • In patients with known epilepsy and recurrent seizures, the same considerations apply, but in addition:
        • epileptic patients with a change in seizure pattern
        • prolonged postictal state
        • persistent abnormal mental status should be scanned in the ED
    • Differential Considerations for the Dx of Seizure
    • Posturing, deviation of eyes Extrapyramidal reactions Myotonic spasms Strychnine and camphor Myotonic spasms Tetanus Buccolingual spasms Phencyclidine Abnormal behavior Hypoglycemia Delirium tremens, blackout Alcohol abuse/withdrawal Toxic and metabolic disorders Loss of urinary continence   Tonic-clonic movements More typical in children Prolonged breath-holding Posturing of extremities   Mood disturbances   Hyperventilation syndrome   Preictal or postictal twitching “ Fit vs. faint” Vasodepressive vs dysrhythmogenic (including long QT syndrome) vs orthostatic Syncope ICTAL-LIKE MANIFESTATIONS CLASSIFICATION DISORDER
    • May closely resemble ictal activity; patients may have both true seizures and pseudoseizures Pseudoseizure Functional disorders Twitching, altered mental state Panic attacks Similar to postictal state, absence status Fugue state Psychiatric disorders Convulsions Hemiballismus, tics Movement disorders Drop attacks, “fit vs. faint” Narcolepsy Drop attacks, “fit vs. faint” Carotid sinus hypersensitivity Todd's paralysis Hemiparetic migraine Similar to postictal state, absence status Transient global amnesia Drop attacks, “fit vs. faint” Transient ischemic attacks Nonictal CNS events
    • Management
      • Lorazepam has emerged as the drug of choice for the initial management of epilepsy
        • it terminates seizure rapidly (within 2 minutes)
        • has a longer duration of action (4 - 6 hrs, compared with 20 mins for diazepam), thus necessitating fewer repeat doses
        • preferred agent for control of alcohol withdrawal seizures
        • available IM and S/L preparation for out-of-hospital control of seizures in children
    • Midazolam
        • onset of action is within 1 minute
        • it is available in both I/N and buccal formulations
        • it has the least cardiovascular effect among the benzodiazepines
    • Intubation required; monitor hemodynamics 10–20 mg/kg IV load over 1–2 hours, then 0.5–1 mg/kg per hour infusion Numbutal Pentobarbital Intubation required; monitor hemodynamics 1–2 mg/kg IV bolus, then 5–10 mg/kg per hour infusion Diprivan Propofol Unlabeled use 20–40 mg/kg at ≤6 mg/kg per minute Depakote Valproate May be given as IM loading dose 20 mg/kg IV, then 5–10 mg/kg every 20 minutes, up to 2 g Luminal Phenobarbital Cardiac monitoring Less risk of infusion site reaction; may be given IM 20 PE/kg IV at 150 mg PE/minute Cerebyx Fosphenytoin Cardiac and blood pressure monitoring during infusion; large-bore intravenous line 20 mg/kg IV at <50 mg/minute Dilantin Phenytoin May be given intranasally (0.2 mg/kg) 0.2 mg/kg IV bolus, then 0.05–0.6 mg/kg per hour infusion Versed Midazolam Preferred benzodiazepine owing to its longer duration of action 0.1 mg/kg IV (usually 4 mg in adult); may repeat in 10 minutes, then 0.01–0.1 mg/kg per hour infusion Ativan Lorazepam May be given per rectum in pediatrics (0.3–0.5 mg/kg) 5–10 mg IV every 10 minutes, up to 30 mg per 8-hour period Valium Diazepam COMMENTS ADULT DOSE BRAND NAME GENERIC NAME
    • 24 yr old male brought to ED by EMS with a new onset seizure of 30 mins duration. He smells of alcohol. His BP is 170/110, HR 150/min and rectal temperature I 101.2 degrees F. he continues to seize in spite of 20 mg of Diazepam. Treatment may include all of the following except:
      • Chemical paralysis & intubation
      • Fosphenytoin up to 30 mg/kg IV
      • Phenobarbital up to 30 mg/kg IV
      • Propofol 2mg/kg IV then 1-15 mg/kg/hr IV infusion
      • Gabapentin( neurontin) 50 mg IV then 0.5 mg/kg/hr IV infusion
      • Pentobarbital 10 mg/kg IV over 1 hr then 0.5-1 mg/kg/hr IV infusion
      • Refractory status epilepticus :
      • patients who remain unresponsive to the third-level choice of pharmacologic intervention
      • general anesthetic doses of midazolam or propofol..infusion
      • barbiturate coma
      • general inhalational anesthesia(isoflurane)
    • The cardiac effects of phenytoin include decreased automaticity & contractility, but significant cardiotoxicity probably only occurs during excessively rapid IV administration. Cardiac effects that can occur when phenytoin is given IV faster than 25-50 mg/min include all of the following except:
      • Hypotension and apnea
      • Ventricular arrhythmias
      • High degree AV heart block
      • Similar cardiac side effects are seen with the IV infusion of fosphenytion
      • The false answer regarding fosphenytoin is :
      • Fosphenytoin is a water-soluble prodrug form of phenytoin, with a more physiologic pH
      • Its main advantages are that it is not likely to precipitate during intravenous infusion and that it also can be administered intramuscularly
      • fosphenytoin can be infused more rapidly so patients can be D/C earlier from ED compared to phenytoin
      • the hemodynamic advantages of fosphenytoin over intravenous phenytoin have not proved to be significant
      • Its use is most appropriate when intravenous access is not obtainable or when the intravenous line is of small gauge, as is often the case in children or the elderly
    • A 31 yr old pregnant lady @ 39 wks gestation presents to ED with HA & blurred vision. Her BP 170/110 and she has moderate leg oedema. During her evaluation, she develops TC seizure.Her management includes all of the following except:
      • Magnesium sulfate 4 gm IV
      • Magnesium sulfate IV drip @ 2 gm/hr
      • Hydralazine 10 mg IV push
      • 20mg/kg phenytoin equivalents of fosphenytoin @ 200mg/min
      • Prompt delivery
    • Long-Term Management
        • The decision to treat should be based on :
          • ensuring that the Dx of seizure is correct
          • ascertaining the likelihood of seizure recurrence
          • assessing the benefit vs risk of anticonvulsant therapy
          • discussing with the patient their approach to risk
      Initiation of prophylactic anticonvulsant therapy after one seizure
    • Patients may be discharged home with early referral to a neurologist
      • if they have a normal neurologic exam
      • no comorbidities
      • no known structural brain disease
      • do not require the use of an antiepileptic drug in the ED
      • are felt to be sufficiently resourceful and reliable to comply with follow-up instructions
    • Conclusion
      • The possibility of reactive seizures should be considered in all patients who present to the ED with seizures or recent history of seizures, including pts with h/o epilepsy
      • Most common cause of :
        • reactive seizures  hypoglycemia
        • recurrent primary seizures  Rx noncompliance
      • Nonconvulsive seizures may be confused with nonictal states, including psychiatric disorders. The presence of repetitive eye movements, blinking, or automatisms suggests the Dx
      • Neuroimaging is recommended for patients with seizures in whom head trauma, elevated intracranial pressure, intracranial mass, persistently abnormal mental status or focal neurologic abnormality, or HIV disease is suspected.
      • Primary abortive therapy for seizures in the ED setting is with a benzodiazepine; second-line agents include phenytoin and phenobarbital.
    • Thank U ??????