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Acute Fits
- 1. Dr Al Buick RoyalDevon and Exeter Hospital The Management of Acute Fits
- 2. Outline • What dowe mean by acute fits? • Different types of seizure • Causes of seizures • Management of acute seizures • Complications of seizures • Some quick cases Meducation The Medical Education Network www.meducation.net
- 3. Definitions – whatdoes it all mean! Meducation The Medical Education Network www.meducation.net Acute Fits EpilepsyStatus Epilepticus
- 4. Definitions – whatdoes it all mean! Meducation The Medical Education Network www.meducation.net Acute Fits EpilepsyStatus Epilepticus What we might also call an acute seizure
- 5. Definitions – whatdoes it all mean! Meducation The Medical Education Network www.meducation.net A prolonged seizure or seizures repeated frequently enough to prevent recovery between episodes occurring over a period of 20-30 minutes. Acute Fits EpilepsyStatus Epilepticus
- 6. Definitions – whatdoes it all mean! Meducation The Medical Education Network www.meducation.net Recurrent episodes of intermittent brain dysfunction due to a sudden, disorderly, and excessive neuronal discharge. This can manifest as a seizure. Acute Fits EpilepsyStatus Epilepticus
- 7. Different types ofseizure Meducation The Medical Education Network www.meducation.net Seizures Partial Generalised Simple Complex Absence Myoclonic Tonic-Clonic Tonic Atonic
- 8. Different types ofseizure Meducation The Medical Education Network www.meducation.net Seizures Partial Generalised Simple Complex Absence Myoclonic Tonic-Clonic Tonic Atonic
- 9. So what cancause a seizure? Meducation The Medical Education Network www.meducation.net
- 10. Causes of seizures-Intracranial Underlying brain pathology • Underlying brain abnormality • Raised intracranial pressure • Cerebral tumour • Cerebral oedema • Pregnant – Ecampsia • Stroke • Thrombo-embolic • Haemorrhagic • Brain infections Meducation The Medical Education Network www.meducation.net GIANT CELL TUMOR, 14 MONTHS WITH SEIZURES
- 11. Extracranial- We couldall suffer fits given the right situation Pyrexia Biochemical • Sodium, Glucose • Calcium, magnesium • Urate Hypoxia – (e.g. Carbon monoxide poisoning) Causes of seizures- Extracranial Drugs • Prescribed • Recreational • Withdrawal
- 12. Management of seizures Youare the F1 on call and it is 3am. You receive a bleep from one of the wards…. “Could you come and see this patient….. they are having fits and we don’t know what to do….. Please come quickly…”
- 13. Management Meducation The MedicalEducation Network www.meducation.net A B C D Airway Breathing Circulation Disability Is their airway patent? Give airway management if needed
- 14. Management Meducation The MedicalEducation Network www.meducation.net A B C D Airway Breathing Circulation Disability • What is the respiratory rate? • What are their oxygen saturations • Give oxygen if needed
- 15. Management Meducation The MedicalEducation Network www.meducation.net A B C D Airway Breathing Circulation Disability • Heart rate • Blood pressure • Peripheral perfusion Capillary refill time
- 16. Management Meducation The MedicalEducation Network www.meducation.net A B C D Airway Breathing Circulation Disability • Other signs •? Head injury •? Bleeding • ? Sign of infection Don’t Forget Glucose
- 17. Management of fits– Stepwise appraoch Meducation The Medical Education Network www.meducation.net Initial A,B,C,D Benzodiazepi ne Phenytoin Paralysis and ventilation Start treating underlying cause
- 18. Management of fits– Stepwise appraoch Meducation The Medical Education Network www.meducation.net Initial A,B,C,D Benzodiazepi ne Phenytoin Paralysis and ventilation Start treating underlying cause
- 19. Benzodiazepine Meducation The MedicalEducation Network www.meducation.net If fit does not resolve after a few minutes consider giving a benzodiazepine Action Enhance effect of GABA which is the main inhibiting neurotransmitter Therefore reduce the excessive neuronal discharge
- 20. Benzodiazepine Meducation The MedicalEducation Network www.meducation.net Side effects to be aware of Sedating and muscle-relaxing action Suppressed breathing Hypotension (worse with IV) Reduced conscious level Nausea Euphoria
- 21. Benzodiazepine Meducation The MedicalEducation Network www.meducation.net Drug Peak onset Half life Midazolam About 1 hour Short (3 hours) Lorazepam About 3 hours Medium (15 hours) Diazepam About 2 hours Long (30+ hours) Chlodiazepoxide About 3 hours Long (30+ hours)
- 22. Management of fits– Stepwise appraoch Meducation The Medical Education Network www.meducation.net Initial A,B,C,D Benzodiazepi ne Phenytoin Paralysis and ventilation Start treating underlying cause
- 23. Phenytion Works on sodiumchannels Blocks voltage-sensitive sodium channels in neurons Delay in neuronal electrical recovery from inactivation Inhibitory effect is dependent on the voltage and frequency of neural cell firing by selectively blocks neurons that are firing at high frequency
- 24. Phenytion Pharmicokinetics Mainly hepaticbreak down Zero order kinetics
- 25. Phenytion Side effects Beware oftoxicity as zero order Arrhythmias (it is a class 1b antiarrhyhmic) Bradycardia Hypotension Bradykinesia, ataxia Sedation, confusion Teratogenicity
- 26. Management of fits– Stepwise appraoch Meducation The Medical Education Network www.meducation.net Initial A,B,C,D Benzodiazepi ne Phenytoin Paralysis and ventilation Start treating underlying cause
- 27. Paralysis and ventilation Ifseizure not managed by the initial methods Amy need to consider paralysis and ventilation Should be done in ITU Expert help required
- 28. Complications of Seizures SUDEP- Sudden Unexpected Death in Epilepsy Brain injury Physical Injury • Direct from fit – Tongue biting fitting • Driving?
- 29. A few clinicalcases…
- 30. Case 1 A 21year old diabetic girl presents to the emergency department having been found out shopping on a Saturday morning. She was reported previously well by her friends and had even been out for some drinks the night before. Her friends tell you she was acting strange and then collapsed. She not not very responsive and 10 minutes later she started fitting. What else do you want to know and what are you going to do?
- 31. Case 2 A 84year old woman is brought in by ambulance having been found at home by her son on the floor. She was unresponsive and has been fitting on an off since she had been found. Her son reports she is normally fit and well and only has bad arthritis, recently given “some sort of patch of the pain” What else do you want to know and what are you going to do?
- 32. Case 3 A 20year old motorcyclist was found having crashed in to a wall. He was brought in by air ambulance. He is barely conscious but responds to pain. He is fitting every 5 minutes and has been for 45 minute since he was found. What else do you want to know and what are you going to do?
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