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Neurology > Seizures > Flashcards

Seizures Flashcards

1
Q

SE differentials

A

Psychogenic
Encephalopathies
Movements disorders (dystonia, tremor)
Migraine
Syncope
Panic attack
Transient global amnesia
Narcolepsy

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2
Q

Status epilepticus midazolam

A

Midazolam 5mg IV or IM
-5mg/5mL ampule
-IV infusion over 2mins
-IM push
-Up to 10mg recommended
-Repeat after 5 mins

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3
Q

Status epilepticus lorazepam

A

Lorazepam IV
-4mg IV recommended
-4mg in 1mL ampoule
-Dilute 1:1 in normal saline

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4
Q

Status epilepticus levetiracetam

A

Levetiracetam
-60mg/kg up to 4.5g loading
-Dilute in 100mL normal saline
-Infusion over 5-15 mins

Preferred option
-already on levetiracetam
-liver failure
-limited drug interactions

Renal dose adjustment needed

Adverse effects
-Hypertension
-Nausea
-Neuropsych changes
-Drowsiness and fatigue

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5
Q

Status epilepticus valproate

A

Valproate
-40mg/kg up to 3g loading
-Dilute in 100mL normal saline
-Infusion over 10mins

Dose adjust in ESRD

Avoid use in mild liver disease

Adverse effects
-Increases other drugs levels, especially phenytoin
-Drowsiness
-Agitation, insomnia, hallucinations, delirium
-Parkinsonism
-Coagulopathy
-Blood dyscrasia
-Hepatotoxic
-Hyperammonaemia encephalopathy
-Pancreatitis

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6
Q

Status epilepticus phenytoin

A

Phenytoin
-20mg/kg up loading
-Can have extra 5-10mg/kg ten mins after loading, to maximum of 30mg/kg
-Undiluted with syringe pump
-Infuse at 25-50mg/min. Increase risk of hypotension and arrhythmias at higher rates
-Incompatible with benzos and glucose. Needs seperate line

Needs continuous cardiac and BP monitoring

Almost entirely metabolised by liver
No renal adjustment required

Adverse effects
-Pancytopaenia
-Hypotension
-Brady/tachyarrythmias
-Drowsiness
-Nystagmus, ataxia, dysarthria
-Gingival hyperplasia
-Hepatotoxicity
-Purple glove syndrome

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7
Q

Status epilepticus second line options

A

Levetiracetam
-60mg/kg up to 4.5g

Valproate
-40mg/kg up to 3g

Phenytoin
-20mg/kg

On phenytoin or valproate
-Recent therapeutic level, give levetiracetam
-Recent subtherapeutic level, give proportionate loading

If on levetiracetam, give levetiracetam, valproate or phenytoin

All equally effective (about 50% at 1hr) and same rates of adverse effects

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8
Q

Seizure causes

A

Metabolic
-hypo/hyperglycaemia
-hyponatraemia
-hypocalcaemia
-hypomagnesaemia
-renal failure

Intoxication

Withdrawal

Stroke

Brain trauma

Intracranial infection

Autoimmune encephalitis

Hypertensive encephalopathy

Severe hypoxia

Eclampsia

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9
Q

Status epilepticus evaluation and management

A

Treat if
-Over 5 mins continuous
-Repeated seizures without full recovery
-Airway or breathing compromise

Continuous observations
Airway
-Simple manoeuvres/adjuncts
-Consider need for intubation
B
-Hudson mask
-BMV if apnoea, hypoxia or cyanosis
C
-IV access
-Fluids
-Pressors
D
-duration
-awareness
-focal signs

Investigations
-Glucose
-VBG
-Bloods, ASM level, beta hCG

Correct hypoglycaemia
Give thiamine if hypoglycaemic

5 mins
-Midazolam 5-10mg IM/IV or Lorazepam 2-4mg IV
-First dose ASM

10 mins
-Second dose benzo

15 mins
-Contact consultant
-Contact ICU

15-30 mins
-Second ASM
-Prepare for RSI

30mins
-ICU
-Intubation
-Midazolam, propofol, phenobarbital infusion

After seizure
-Monitor back to baseline
-EEG
-Brain imaging
-LP after brain imaging if concerned for infection

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10
Q

Define acute symptomatic seizure

A

Occurs at the time or in close temporal relation to systemic or brain insult
-Stroke
-Encephalitis
-Head injury
-Metabolic derangements
-Withdrawal

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11
Q

Define unprovoked seizure (remote symptomatic)

A

Carries higher risk of epilepsy

Unknown aetiology
or
Occurs in relation to
-Pre-existing brain lesion
-Progressive neurological disease

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12
Q

Define epilepsy

A

Two unprovoked seizures >24hrs apart

One unprovoked seizure plus >60% risk of recurrence within 10 years due to stroke, TBI, CNS infection

Diagnosis of an epilepsy syndrome

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13
Q

Focal seizure with retained awareness features

A

Symptom depends on seizure location
Onset of symptoms overs seconds
Usually last <3 mins
May be focal to generalised
May have an aura
May have no post ictal period
May have prolonged worsened neurological function in specific area (eg Todds paralysis)

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14
Q

Focal seizure with impaired awareness features

A

May have impaired awareness from start
Symptom onset over seconds
Usually last <3 mins
Can have retained awareness initially, which may be remembered
May be focal to generalised
May have an aura
Motionless or automatisms
Usually has post ictal phase lasting up to hours

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15
Q

Generalised seizure features

A

Impaired awareness
Bilateral features

Usually last <3 mins

Tonic clonic
-Increased tone, may have cyanosis
-Then jerking and twitching, may have tongue biting
-Deep sleep, slow breathing, gradually waking up
-Post ictal period

Absence
-Mainly in children
-Usually brief (<10s) episodes
-May be dozens of times a day
-Behavioural arrest, blank face, impaired awareness
-Automatisms if prolonged

Clonic
-Rhythmic jerking movements
-More prolonged than myoclonic

Myoclonic
-Brief singlular or cluster of muscle contractions
-Typically arms
-May have retained consciousness

Tonic
-Sudden stiffening

Atonic
-Drop attack
-Loss of tone, usually causing fall

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16
Q

Psychogenic seizure discriminatory features

A

-Fluctuating asynchronous movements
-Eye closure
-Head side to side
-Pelvic thrusting
-Alert despite bilateral features
-Tongue biting rare
-Rarely <1min, often >30 mins
-Variable recall

17
Q

Syncope discriminatory features

A

-Usually preceding symptoms unless cardiac
-May have myoclonus or tonic posturing
-Usually lasts 1-2 mins
-Can usually recall prodromal symptoms

18
Q

TIA discriminatory features

A

-Maximal onset symptoms
-Symptoms depend on location but typically negative
-Usually retained awareness
-Lasts several minutes to hours
-Recall intact

19
Q

Migraine aura discriminatory features

A

-Symptoms evolve over >5 mins
-Positive and/or negative symptoms
-Usually visual or sensory
-Usually positive then negative
-Usually followed by headache
-Lasts up to an hour
-Complete recall
-Family or personal history of migraine

20
Q

Panic attack discriminatory features

A

Triggering event
History of anxiety or depression
Palpitations, chest pain, dyspnoea, lightheaded
Sense of impending doom
Hyperventilation with perioral or limb paraesthesia
Lasts minutes to hours
Complete recall

21
Q

Transient global amnesia discriminatory features

A

Rare under 50 yrs
Prominent anterograde and variable retrograde amnesia
Disoriented in time
Asking repetitive questions
Other cognitive and motor functions spared
Lasts 1-10 hours
Complete amnesia for main episode
Retrograde amnesia resolves within 24hrs

22
Q

Seizure history

A

Description of event
-Focal or generalised
-Awareness impaired or retained
-Speed of onset
-Duration
-Tongue biting
-Incontinence

Post ictal
-Confused and drowsiness common
-May have prolonged decreased focal neurological function
-May last seconds to hours (usually within 20 mins)
-Should show gradual improvement

Triggers
-Strong emotions
-Exercise
-Loud music
-Flashing lights
-Intoxication and withdrawal

Predisposed
-Fever
-Menses
-Pregancy
-Sleep deprived

Prior events
-40% have unrecognised prior events, 3/4 of which are non convulsive
-Myoclonus after waking (young)
-Olfactory, gustatory, visual hallucinations
-Fear, panic, anxiety

Past medical
-Epilepsy risk factors

Family history
-seizures or epilepsy

Medications
-Prescription and over counter
-Alcohol
-Drugs

23
Q

Past medical risk factors for epileptic seizures

A

Neurodevelopmental issues
Intellectual disability
TBI
Stroke
Alzheimers
Neurological infection
Alcohol or drug dependency
Immunosuppressed
Malignancy
SLE
Haematological: sickle cell, porphyria, APLS

24
Q

First seizure investigations

A

Glucose

ECG
-Ischaemic
-AV block
-QT prolongation

Routine bloods
-Lactate
-Prolactin only if possible generalised psychogenic seizure

CT brain

Outpatient/non urgent MRI brain

EEG
-Urgent if prolonged status or post ictal
-Outpatient/non urgent for rest

Lumbar puncture
-Only if concern for infection
-Only after space occupying lesion excluded

25
Q

Seizure recurrence risk >60% within 10 years

A

Unprovoked seizure plus
-Epileptiform features on EEG
-Remote symptomatic cause
-Focal neurological findings
-Intellectual disability
-Seizure during sleep

26
Q

First unprovoked seizure management

A

Recurrence risk factor present
-start ASM

No recurrence risk factor
-Recurrence risk 50% in 2 years
-Risk reduced by 30% with meds. No change in risk after 2 years
-Can usually defer starting ASM
-Start ASM if second unprovoked

Neurologist review for all

Inpatient admission
-Prolonged seizure or post ictal
-Not returned to baseline
-Possible provoking insult

Trigger avoidance
-Sleep
-Stress
-Medications
-Drugs and alcohol

Risk reduction
-Swimming and bathing
-Driving
-Heavy machinery

27
Q

First provoked seizure management

A

All require neurology review and inpatient admission

Start ASM if any of following present
-Prolonged seizure (>3 mins)
-Recurrent seizure (>1 event)
-TBI
-Ischaemic stroke or ICH
-Critical illness
-Active underlying condition

Cease after reversible causes resolved
-Metabolic derangements
-Intoxication
-Withdrawal

ASM withdrawal is individualised for acute brain injuries
-Stroke
-Intracranial infection
-TBI

Neurology (7 decks)

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