3. objectives
To be able to know definition of seizure,GCSE,NCSE
To understand epidiomology,clinical features of seizure &SE
To know basic pathophysiology of seizure
To identify major causes of provoked seizure
To understand the management principles
4. DEFINITION
SEIZURE- are excessive abnormal neuronal activity associated with
alteration sensory , motor , autonomic dysfunction and/or
cognitive function.
CONVULSION- refers specifically to the motor manifestation of a
seizure
POSTICTAL PERIOD- an interval of altered mental status immediately
following a seizure, generally lasting less than 1hr.
EPILEPSY- refers to a condition of recurrent unprovoked seizures.
5. Cont..
Acute symptomatic seizure-refers to
a seizure that occurs at the time of a systemic insult or in close temporal
association with documented brain insult.
-within 01 wk. of stroke ,TBI , anoxic encephalopathy or intracranial
surgery
-during active phase of CNS infection
-within 24 hrs. of severe metabolic derangement
-account up to 25-30% of 1st seizure and has low risk for future
epilepsy
6. …
Unprovoked seizures- seizure of unknown etiology as well as one that
occurs in r/n to a preexisting brain lesion or
progressive nervous system disorder
. Status epileptics - ≥ 5 min continuous seizure or
- ≥ 2 discrete seizure b/n w/c there is incomplete
recovery of consciousness
.
7.
8. …
FOCAL SEIZURE WITH RETAINED AWARENESS
The symptoms vary from one patient to another and depends entirely on
the part of the cortex that is disrupted
occipital lobe - may result in flashing light
motor cortex- jacksonian march
parietal cortex-spatial perception
frontal lobe - sudden speech difficulties
temporal lobe- gustatory or olfactory hallucination
9. …
FOCAL SEIZURE WITH IMPAIRED AWARENESS
- the most common types of seizure in adults with epilepsy
- typically lasts less than 3 min and may begin with a preserved
awareness
-postictal phase- somnolence ,confusion and headache for up to
several hrs.
- symptom can be bizarre
10. Cont..
Automatism - lip smacking , fiddling with cloth or button, repeating
short phrases
Visceral - sensation of butterflies rising from epigastrium
Hallucination- visual, olfactory ,auditory or gustatory
Affective symptoms- fear, paranoia, depression, elation
Memory disturbance
Distorted perception
11. Cont..
Absence or petit mal seizure - manifest as brief dissociative states,
often without muscle or postural change
- resume previous activity without postictal symptoms
- classic one occur on school age
- the attack can occur more than 100 within a day and affect school
performances
- usually resolve as a child mature
12. Cont..
Generalized tonic-clonic seizure- most common types
Tonic phase- all muscle of the arm, legs, chest and back becomes
stiff. Patient become cyanotic during
this phase..20sec
Clonic phase- the muscle begin to jerk and twitch for additional
30sec-1min
Postictal phase- begin once twitching movement end
13. EPIDEMIOLOGY
bimodal distribution among infant and > 75yrs old
45% adult with 1st unprovoked seizure experience another within 2 years ,
most within 1 year
Up to 50% of patients with epilepsy have recurrent seizure despite
initiation of therapy
account for 1-2% of all emergency department visit
18. Cont..
typically seizure are self limited. This may be
- related to reflex inhibition
- loss of synchrony
- neuronal exhaustion
- alteration of local balance of NT in favor of inhibition
19. Clinical Feature
Is it a seizure?
-circumstance
-as general rule ,no single C/F or diagnostic modality is 100%
confirmatory for occurrence of neurologic seizures
-strong markers of seizure -post octal confusion
-tongue biting
-cyanosis
- confirmed unresponsiveness
-preceding dejavu or lamias vu
-head/eye turning to one side
-dystonic feature
20. Hx
hx of trauma
hx alcohol intoxication or abuse
pregnancy
fever or headache
incidence of seizure with stroke-5-15%, epilepsy 4-9%
non compliance with anticonvulsant
hx of nonneurologic comorbid disease
21. P/E
vital sign
irregular heart rate
pupillary rxn
postictal confusion...failure to improved can be caused by
-NCSE -CNS infection
-metabolic encephalopathy -vascular event
-drug toxicity -migraine
-hypoglycemia
23. DDX
SYNCOPE- usually present with prodromal symptoms
- can be associated with injury,incontinence,or even breif
tonic clonic activity
- often has provocative cause, the LOC is brief and return
to full consciousness is prompt without a confusional
state
24. Pseudo seizure
o Psychogenic in origin associated with
conversion disorders, malingering
Brief psychosis, panic disorders
o Usually in response to emotion upset
o Often bizarre and highly variable
o Pt able to protect them selves
o Characteristic movements
Side to side head thrashing, pelvic thrusting
25. Cont..
Clonic alternating extremities movement
Incontinence and injury are uncommon
No postictal confusion
Often stop seizure like activities on command
Accurate diagnosis needs EEG and video monitoring
27. Cont..
Hyperventilation syndrome
Gradual onset of attacks with shortness of breath, anxiety &perioral
numbness.
Post ictal symptoms are rare
Asking the pt to hyperventilate will be reproduced.
28. INVESTIGATION
RBS
Metabolic panel...Na, Ca, Mg
pregnancy test
toxicology screen
serum lactate and prolactin level
serum anticonvulsant level....therapeutic level
29. Cont..
Imaging...CT scan
...MRI
Lumbar puncture...febrile,immunocompromised
possible SAH
EEG...NCSE
...subtle SE
...ongoing SE despite TX
30. Empirical management
Prehospital
Prompt recognition of
Hypoxia
Hypotension
Hypoglycemia
Place in a lateral decubitus position
Oral air way
benzodiazepines
31. …
Emergency treatment
Place in monitoring bed
Oral airway contraindication
Administer O2
Lorazepam iv,midazolam IM
PHENYTOIN 20mg /Kg to max of 50 mg/min/
Fosphenytoin 20 PE/Kg/max of 150/min/
Valproic acid 20-40mg/Kg at 3-6mg/Kg/min
32. …
If seizure continues
Half loading phenytoin,fosphenytoin,valproic acid
Levetiracetam iv bolus 1-3 gm./15 min
At 20-60mg/kg
If seizure continues
Rule out reversible causes
Bleeding,drugoverdose
Prepare for RSI &administer 3rd line therapy
33. …
INH overdose cause refractory seizure to benzodiazepines
Pyridoxine
If Child bearing female is seizing
Consider eclampsia which is mgso4 responsive.
Children &psychiatric pts. at risk of water intoxication
Hyponatremia requiring hypertonic saline
34. …
Patient with Hx of seizure
-depends on the particular circumstance of of the case
-identify and correct potential precipitant that lower the thresholds
-medication nonadherance...serum anticonvulsant
-if they are adequate... no need of specific tx
-if anticonvulsant level not available- give the usual dose
-if precipitant cant found- change/adjust the dose
35. …
Patient with 1st Unprovoked seizure
- as long as the patient returned to neurologic baseline , hospital
admission and initiation of anticonvulsant is not recommended
- predictors of seizure recurrence.. cause of the seizure
. result of EEG
-Ideal antiepileptic drug- single drug therapy with minimal toxicity
-drug selection based on seizure types
-precaution. Swimming, working with hazardous material/heights
driving license??
41. convulsive status epileptics
DEFINITION - ≥ 5 min continuous seizure or
- ≥ 2 discrete seizure b/n w/c there is incomplete
recovery of consciousness
The ILAE published conceptual defn of SE that incorporates two operational dimensions, t1
& t 2
- SE is a condition resulting from either the failure of the
mechanism responsible for seizure termination or from the
initiation of mechm that leads to abnormally prolonged sz. t1
- SE is a condition that can have long term consequence depending
on the type and duration of sz. t2
42. …
For GCSE..t1 5min and t2 30 min
Focal SE with impaired conciousness..t1 10 min and t2 > 60 min
Absence seizure..t1- 10-15min
..t2 no data available
43. …
EPIDEMIOLOGY- incidence follows U shaped distribution, highest in
<1yr and > 60 yr
- over a lifetime up to 10% adult with epilepsy and 20% of children
with epilepsy have one/more episodes SE
ETIOLOGY - in children febrile seizure is the most common causes
- in adult, acute symptomatic seizure the most common
followed by remote symptomatic and low anti epileptic
drug
44.
45. 1. GCSE - the most dramatic form of SE ,with potential for serious
complications, morbidity and mortality
-includes both 1 and 2ry generalized
-there is always impaired consciousness and bilateral tonic
stiffening, followed by rhythmic jerking of the limbs
46. …
2. Focal motor SE -many clinical feuture and largely depends on
epileptogenic brain area
-in almost all cases there is associated focal lesion
EPC(epileptia partialis continua)- a particular refractory focal motor SE
with a very prolonged & very regular jerking activity
- EPC remarkably persistent lasting days , wks,or
even decades
- often restricted to one part of the body and slower than
most other forms focal motor SE
47. …
3. Myoclonic SE(MSE) - is characterized by frequent myoclonic jerks
that can be rhythmic or arrhythmic
- are often generalized but some are focal
- causes divided into epilepsy syndrome related
and symptomatic causes
1. primary epilepsy syndrome -myoclonus is characteristic finding
2. secondary epilepsy syndrome
3. symptomatic MSE- anoxia, encephalopathy
→
48. EEG
- During GCSE , EEG often obscured by muscle & movt artifact but it may
show continuous spike & wave activity indicative of generalized sz activity
- Once convulsion ceased EEG is crucial in determining whether SE is truly
ended
- During focal motor SE , EEG can be subtle or absent- deeper seizure
- orientation
- intermittent
- In myoclonic SE ,EEG helps to differentiate types of MSE
50. Treatment
Early recognition & treatment are critically important
mortality dramatically increase with delayed diagnosis and initiation of
treatment
the goal of treatment is to control as soon as possible & within 30 min of
presentation
Initial management divided into three phases
1. Rapid assessment and support- attention to ABC is urgent
- supportive therapy( eg O2& MV)
-at least two iv catheter
-cardiac monitor, bp , pulse
51. …
NM blocking agent facilitate intubation but can abolish the motor
manifestation of seizure & thus mask ongoing SE
If NM agent used EEG monitoring is mandatory
midazolam and thiopental are preferred to facilitate rapid intubation
52. …
2. Initial pharmacology treatment
Benzodiazepines are first line treatment
lorazepam - 0.1mg/kg ,max rate 2mg/min, or 4mg fixed dose loading
- repeat the dose if pt still seizing after one min
- no definitive maximum dose
- even if seizure stops following benzodiazepine loading dose
of antiepileptic should follow
53. …
diazepam- has high lipid solubility and can rapidly cross BBB
- 0.1-0.3mg/kg IV
- an effect can be seen 10-20 sec and CSF concentration
reach maximum within 03 min
- 50 -80% of initial termination of seizure but 50% chance of
recurrence within 02hr if no antiepileptic given
54. …
when IV access not available
- IM midazolam is safe and effective
- 10mg IM,nasally or bucal >40kg..5mg for pt 13-40kg
- rectal diazepam - onset 2-10min
56. …
Fosphenytoin- water soluble converted into phenytoin in the plasma
- similar onset and effectiveness as phenytoin
- fewer infusion site rxn and CV effect due to lack of
propylene glycol and ethanol as solvent
- may be infused quickly and can also given IM
- loading 20PE/kg, infusion 150PE/min over 10-15 min
57. …
Phenytoin - typically infused not faster than 25mg/min due to
myocardial depression
- shouldn’t be given IM and with glucose solution
- contraindicated on 2nd & 3rd degree block
- stop and restart with lower dose if side effect occur
- both phenytoin and fosphenytoin intensify seizure caused
by cocaine, theophyline...
58. …
Valproate -available data suggest valproate is as effective as
phenytoin
- shouldn’t be administered along with phenytoin
- hepatic toxicity, hepatic encephalopathy, pancreatitis
- dose 20-40 mg/kg
. levitracetam - not yet FDA approved
. lacosmide
59. …
Postictal recovery - most patient begin to recover within 20-30 min after
GCSE
- the two most important common reason for
postictal recovery are sedation & NC sz
- of 164 patients with GCSE EEG monitoring was done
postictal- 52% had no evidence of ongoing ictal
discharge- 13% mortality
- 14% had NCSE-51% mortality
- 34% non continuous rythimic discharge
32% mortality
61. Refractory SE
IS defined as persistent seizure activity despite the IV administration of
adequate amount of two antiepileptic drugs
usually exceed 60 min
20-31% SE develop refractory SE
single vs combination agents
62. …
Propofol- can be started 2-10mg/kg/hr and titrated up to seizure
cessation
- has a short half life w/c allow quicker neurologic recovery
- propofol infusion syndrome
- if seizure are controlled with propofol ,effective effusion
should be maintained for 24 hr ,then tapper at dose of 5%
per hr
63. …
Midazolam- water soluble
- initiated with 0.2mg bolus given at rate of 2mg/min
- additional bolus can be given every 05 min
- continuous infusion 0.1mg/kg/hr max 3mg/kg/hr
. Pentobarbital - initial dose 5mg/kg over 10 min
- infusion 1mg/kg/hr
. Ketamine - 3rd line agent
- dose bolus 0.5-4.5mg/kg or infusion 5mg/kg/hr
66. Noncovulsive SE
ILAE defines SE as a condition resulting either from failure the
mechanism responsible for seizure termination or from initiation
mechanism that leads to abnormally prolonged seizure
the temporal threshold that define an abnormally prolonged seizure
depends on the type of seizure - convulsive- 05 min
- NCSE- 10min
67. …
Electro clinical classification- NCSE is subdivided according to level of
consciousness & clinical & EEG features
1. NCSE without coma
A. Generalized NCSE - typical absence SE
- atypical absence SE
- myoclonic absence SE
B. Focal SE with/without impairment of SE
- aphasic SE
68. …
2. NCSE in coma - around 8-20% of comatose patient who have not had
any clinical seizure activity will have EEG finding
consistent with NCSE at the time of monitoring
- aftermath of CSE - 14%
69. …
Etiology
- approximately 1/2-2/3 of pts. have a prior hex of seizure or epilepsy
- almost the same etiology with convulsive SE
- Drug induced NCSE on critical ill pts. & cancer pts. being treated with
multiagent chemotherapy should considered- beta lactam eg.cefipem
- New onset refractory SE( NORSE)- RSE for which no etiology
identified within 48hr
70. …
C/F - impairment of consciousness ranges from mild confusion to coma
- other c/f divided into two general category
a. negative symptoms- aphasia, mutism, catatonia
b. positive symptoms- tonic eye deviation, lip smacking
trippus, nystagmoid eye jerking
- 3/4 of patients with NCSE have no discernable clinical correlation
& EEG monitoring for diagnosis
71. …
DX
1 EEG - the diagnosis of NCSE requires EEG
- patient selection for EEG
. aftermath of GCSE
. critically ill who are obtunded or comatose
. duration of monitoring?
2 Acute IV ant seizure drug trial
3 Neuroimaging
72. …
Treatment
- delay in dx & tx associated with higher mortality
- initial treatment benzodiazepines with non-coma inducing IV
ant seizure
- How aggressive should one treat?
1. subtle SE from generalized convulsive SE
2. NORSE
3. acute brain injury associated NCSE
73.
74. References
UpToDate 2018
Tintinalis 9th Edition
Rosen Emergency Medicine 9th Edition
Adams and Victor Principles of Neurology 8th Edition
