3-30 Syncope & Seizures

Question 1

How big of a problem is LOC? How is it viewed by medical professionals? Family?

Answer 1

—Loss of consciousness is a common reason for a trip to the emergency department or the primary care office

—Approximately 50% of people will lose consciousness at least once in their lifetime

—It is always viewed as a medical emergency, and demands a medical explanation if at all possible

—A first loss of consciousness may be the beginning of a life threatening illness, or part of a more benign disorder

—A terrifying experience for family and friends

Question 2

What is LOC?

Answer 2

—LOC: loss of consciousness

—Found down: slang term, but accurate sometimes when there is no witness at the time LOC occurred

Question 3

What’s the difference between syncope, faint, and seizure?

Answer 3

—Syncope: loss of consciousness from a lack of blood flow to the brain

—Faint: syncope, most likely vaso-vagal, due to bradycardia and hypotension via the vagus nerve

—Seizure: neurological changes due to a sudden electrical discharge in the brain

Question 4

Why are witnesses important in episodes of LOC?

Answer 4

—It is crucial to check for any witnesses to the LOC, since many patients will have limited or no memories of how they blacked-out

Question 5

What are important questions to ask someone who has had LOC?

Answer 5

Was there a warning, light headedness or dizziness, loss of vision, nausea, sweating, pallor or gray color, shaking or convulsion, open or closed eyes, standing or lying or sitting position, unprotected fall or gradual, duration of unconsciousness, speed of recovery to normal consciousness, has this patient had a previous LOC?

Question 6

What is the most common cause of LOC?

Answer 6

Syncope

—From Greek words meaning “a cutting short”

Question 7

What causes syncope? What does the brain require to function and remain conscious?

Answer 7

—Generally meant as a lack of sufficient blood flow to continue the metabolism of brain cells sufficiently to preserve consciousness

—Consciousness requires a functioning brain stem and one cerebral hemisphere; loss of the brainstem’s reticular activating system OR part of both cerebral hemispheres will cause LOC

—The brain is absolutely dependent on a minimum blood pressure, glucose concentration and partial pressure of oxygen

Question 8

What are some cardiac causes of syncope? Non-cardiac?

Answer 8

Question 9

What is a faint? What causes it?

Answer 9

Vaso-vagal syncope = faint

—Vasovagal syncope is caused by combination of —sympathetic withdrawal (vasodilatation) and —increased parasympathetic activity (bradycardia)

Question 10

What can precipitate vasovagal syncope? What do patients often have a history of?

Answer 10

—Precipitated by:

—Hot or crowded environment, ETOH, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situation:

—Church services, funerals, military activities, athletic activities

—Blood drawing, insertion of an intravenous line, dental work

—Sometimes there is no apparent precipitant at all

—Patients may have a long history of vaso-vagal syncope going back to their childhood

Question 11

What are the SSXs of vasovagal syncope?

Answer 11

—The period of unconsciousness is usually less than a minute, and full recovery of consciousness occurs within five minutes

—Patients will gradually remember their symptoms, and the fact that they lost consciousness quickly

—Upon awakening they may need to move their bowels or urinate

—Often the patients feel cold and sweaty

Question 12

Do patients have a warning for vasovagal syncope? What do they often feel during an episode?

Answer 12

—Normally a brief warning of seconds or minutes

—Patients feel “light, woozy, dizzy,” and notice their vision dims in both eyes, sounds become muffled or the ears seem to ring, there may be palpitations, difficulty breathing, nausea, increased perspiration, a “clammy feeling”, numbness in the hands

—Usually no biting of the tongue or urinary incontinence

—May be able to cushion their fall

Question 13

What causes cardiovascular syncope?

Answer 13

—Cardiac Output= Heat Rate x Stroke Volume

—Due to decreased/insufficient cardiac output caused by:

—Cardiac arrhythmias

—bradyarrhythmias

—tachyarrhythmias

—Structural cardiac abnormality:

—Left ventricular myocardial pathology of various causes causing decreased myocardial motility

—flow obstruction

Question 14

What cardiac disorders can cause syncope?

Answer 14

—Virtually any serious cardiac disorder can cause syncope when there is inadequate blood flow to the brain

—New onset of arrhthymias are common causes of syncope, especially ventricular tachycardia and ventricular fibrillation, both of which can cause sudden death

Question 15

What is the role of heart rate in considering syncope?

Answer 15

—The heart rate itself is very important; only fairly healthy patients can tolerate a pulse less than 40 beats per minute or a pulse greater than 180 bpm

—A sudden change in pulse is very common; atrial and ventricular arrhythmias, sick sinus syndrome, the tachycardia bradycardia syndrome

Question 16

What are some common cardiac causes of syncope?

Answer 16

—Disorders which limit the stroke volume due to obstruction are also important to consider

—1. Aortic stenosis, especially in the elderly

—2. Idiopathic subaortic hypertrophic cardiomyopathy; this may cause syncope or sudden death in high school and college athletes

—3. Mitral valve prolapse, very common in young women, may cause syncope

Question 17

What is situational syncope?

Answer 17

—Certain conditions can cause syncope, especially in elderly patients

Question 18

What is cough syncope?

Answer 18

A type of situational syncope

—COUGH SYNCOPE: repeated coughing, especially in patients with chronic lung disease, may increase thoracic pressure and lower venous return to the right atrium; usually a brief period of LOC

Question 19

What is micturition syncope?

Answer 19

—MICTURITION SYNCOPE: elderly patients, almost always men who stand to urinate late at night, LOC due to the vagal response needed to urinate in patients who are sleepy; clinicians like to call this “Pee Syncope”

Question 20

What are some other examples of disorders that may resemble syncope?

Answer 20

—Hypoglycemia

—Anemia

—Hypoxia

—Diminished carbon dioxide due to hyperventilation

—Anxiety attacks

—Hysterical fainting

—Seizure

Question 21

What is the definition of a seizure?

Answer 21

—Seizure definition: A widespread electrical discharge originating in the neurons of the cerebral cortex, causing an abrupt loss or decline in consciousness, new movements, altered bodily sensation, or unusual psychic feeling; perhaps in some cases by sub-cortical neurons

—An apparent widespread synchronized depolarization of many neurons which would normally be without such synchrony

Question 22

How quickly do seizures happen? What are they mediated by?

Answer 22

—The patient is suddenly affected, or “seized”

—Mediated by changes in ion channels, such as sodium, potassium and calcium, and by neurotransmitters, such as glutamate, and gamma amino butyric acid

Question 23

What is the definition of epilepsy?

Answer 23

—Epilepsy is the condition of two or more spontaneous (UNPROVOKED) seizures

—Epilepsy suggests a disease of brain function, either hereditary or acquired

—Epilepsy comes from Greek words meaning “seized by forces from without”

—An ancient disease, described by the Babylonians, and well known to Greek and Roman physicians, including Hippocrates, one of the first to suspect that seizures came from the brain

Question 24

What is the preferred term for epilepsy and why?

Answer 24

—The preferred term now is SEIZURE DISORDER

—Seizures are still often called “FITS” in the United Kingdom, but this term is considered politically incorrect in the United States

—In the 21th century, epilepsy is still a useful term, but continues to carry some negative connotations

—Some people still don’t know it is a medical disorder

—Patients seldom want to be called “epileptics”

Question 25

What are provoked seizures?

Answer 25

Provoked, AKA Secondary Seizures

—The majority of patients with a first seizure or even multiple seizures, will be found to have a cause, or provocation for this

—Therefore, these patients are not truly epileptics, especially if the cause is temporary or can be reversed

—There is a long list of causes of these provoked, seizures

Question 26

What are 2 of the most common causes of provoked seizures?

Answer 26

1. Hypoglycemia, which may also cause syncope
2. Alcohol withdrawal: patients have one or a few seizures after being intoxicated, within the range of 7 – 72 hours, but typically less than 48 hours after they stopped drinking

Question 27

What are some other common causes of provoked sizures?

Answer 27

—Metabolic: hyponatremia, hypomagnesemia, hypocalcemia, hypoxia

—Fever in young children “febrile seizures”

—Benzodiazepine withdrawal (lorazepam, alprazolam)

—Illicit drugs: cocaine, methamphetamine

—Prescription dugs: antidepressants (bupropion), antipsychotics, amphetamine (stimulants)

—Head trauma, especially severe trauma causing LOC

—Brain tumors, primary or metastatic

—Brain hemorrhages

—Strokes, especially embolic strokes

Question 28

What are idiopathic epilepsies?

Answer 28

—These are patients who have seizures for no known cause, most likely due to genetic conditions, or acquired disorders that can’t be determined, even with neuroimaging, lumbar punctures, and blood tests

Question 29

What is the workup for a seizure?

Answer 29

—Every patient with a first seizure, especially an adult, should be evaluated with a full history, physical examination and neurological examination, an MRI of the brain and full blood tests

—Not every child needs an MRI scan

—An electroencephalogram is often very helpful

—Rarely is a lumbar puncture essential

Question 30

What should be considered when diagnosing a seizure disorder?

Answer 30

—Do NOT diagnose patients unless there is strong evidence from the history, due to reliable witnesses, of two or more unprovoked seizures

—If the history is limited, or doubtful, wait for more evidence before diagnosing

Question 31

How do EEGs help in diagnosing a seizure disorder?

Answer 31

—An electroencephalogram EEG may be helpful but is only an aid to the history:

1. A few patients who do indeed have seizures may have a normal EEG
2. At least 5 -15 % of patients who DO NOT have seizures will have some mild epileptic findings on an EEG

Question 32

What is the role of EEGs in dx’ing seizures?

Answer 32

—An EEG is helpful but seldom diagnostic with epilepsy, with perhaps the exception of absence seizures

—Strong amplifiers show electric potential differences between pairs of electrodes on the scalp, resulting from many post synaptic excitatory and inhibitory potentials (EPSPs, IPSPs)

—Most (but not all!) patients with epilepsy will eventually show spikes or sharp waves on an EEG, but some normal patients show abnormalities on this test

—A normal EEG does NOT mean a patient cannot be having seizures

Question 33

How are sizures classified?

Answer 33

Question 34

What is another name for generalized tonic clonic seizures? Are they common?

Answer 34

—Sometimes called “grand mal,” presumably French for “big and bad”

—Extremely common cause of seizures for which patients and their families seek immediate medical attention

Question 35

When do generalized tonic clonic seizures start? What are the causes of them?

Answer 35

—Often start in adolescence and the twenties, seemingly never in infants under five months or so of age

—Can be idiopathic, presumably genetic, or from any of the secondary causes

Question 36

What do patients experience during a tonic clonic seizure? What do they do during these seizures?

Answer 36

—Patients may get a brief warning, or “aura” which is actually the beginning of the seizure

—First have a tonic phase, with clenching or tightening of the muscles in a fixed position, arms may be flexed, legs are extended, breathing muscles may be locked, and the mouth may close quickly causing biting of the tongue or lip and loss of urinary and rarely bowel continence

—The eyes often roll upward and should be OPEN at the stat of the seizure

—Followed in approximately 10 – 30 seconds by the clonic phase, with repetitive synchronous movements of the arms and or legs

Question 37

How do tonic clonic seizures wrap up?

Answer 37

—The seizure usually ends within two minutes with a gradual slowing of the frequency of repetitive movements

—Respiration resumes

—Patient remains unresponsive for 5 minutes or more, typically, and only slowly gains some orientation after that

—Patients have no memory of the seizure, other than how they felt immediately before, or the aura

—Often awaken in an ambulance or emergency department without any idea of what happened to them; may be combative or “agitated” at that time

—Patients may be somewhat confused (POST ICTAL) for hours, or even days in elderly patients

Question 38

What happens to the heart, O2 sats, and other vitals during tonic clonic seizures?

Answer 38

—The heart rate will increase immediately

—The oxygen saturation of the blood, if measured, will drop

—Blood pressure will increase

—The pupils often dilate widely for a while and will not react to light

—Blood tests may reveal a metabolic acidosis with a decline in serum bicarbonate ion

—Occasionally patients will remain weak on one side for another day due to the seizure focus itself: Todd’s Paralysis

Question 39

Why are partial complex seizures named the way they are? Are they common, easily recognizable?

Answer 39

—“Partial,” because they stay within one cerebral hemisphere

—“Complex” because unlike partial motor or partial sensory seizures, the level of consciousness is partly reduced

—Very common, but not as easily diagnosed as tonic clonic seizures, even if there are witnesses

Question 40

What feelings do patients get during complex partial siezures?

Answer 40

—Patients may get an aura more commonly than with tonic clonic seizures:

—Déjà vu: surroundings look strangely familiar

—Jamais vu: familiar surroundings look unfamiliar

—Bad sensations such as an irritating smell or taste, a sense of dizziness, or an abdominal discomfort which rises to the head quickly

Question 41

When do complex partial seizures occur? What are they often due to?

Answer 41

—Can occur at any age, including the very elderly

—Often occur when patients are alone, or if witnessed, assumed to be transient ischemic attacks or other “spells”

—May be due to trauma, often seemingly mild head trauma

Question 42

How long do complex partial seizures last for?

Answer 42

—Last one or two minutes, typically, and the patients seldom know they are having a seizure, and there is a post ictal period usually shorter than for a tonic clonic seizure

Question 43

What do patients frequently exhibit when they have a complex partial seizures?

Answer 43

—May begin with a sudden loss of speech, a blank look on the face, and AUTOMATISMS:

—1. repetitive blinking, chewing movements of the mouth, simple motioning with the hands, odd fumbling with clothes or even undressing, repetition of very simple spoken phrases or words

Question 44

What are Absence Seizures? Who do they commonly affect?

Answer 44

—Brief episodes, mostly less than 10 seconds in duration, always less than 60 seconds, of inability to speak or respond in any way

—Patients do not fall down, except in atypical absence

—Occasionally blink or have repetitive movements of the face, eyes or arms

—Patients quickly recover a normal level of consciousness and do not even known they have had a seizure

—A very common cause of seizures in CHILDREN

—Formerly known as Petit Mal seizures, a term best avoided at this time

Question 45

Who is affected by Absence Epilepsy?

Answer 45

—These are generally very healthy children, who never have brain lesions, and are assumed to be victims of a genetic disorder

Question 46

Who first notices children suffering from absence epilepsy?

Answer 46

—However, they may have HUNDREDS of these seizures per day, and do poorly in social situations or in their school work

—Often diagnosed by an observant kindergarten or early elementary school teacher who notices the child staring or day dreaming quite often

—Parents are often frustrated when these children don’t seem to listen or respond to questions

Question 47

What is the prognosis for absence seizures?

Answer 47

—The prognosis is very good, unless atypical seizures develop, and then there is usually evidence of loss of developmental milestones

—The vast majority of children are neurologically normal, and two thirds of children will stop having seizures during their teenage years

—Some of them will develop generalized seizures

Question 48

What do absence seizures look like on EEG?

Answer 48

Absence seizures: EEG shows Three per second spike/wave complexes

Question 49

How is absence epilepsy generally treated?

Answer 49

—Patients usually respond to a small dose of valproic acid

—Ethosuximide is equally effective for absence, but it is not effective for tonic clonic seizures, and not as readily available as valproic acid, so it is not used much anymore

—And, valproic acid is a highly prescribed drug, for bipolar disorder and migraines as well as epilepsy, so all pharmacies keep it in stock

Question 50

Are anti-epileptics generally indicated after 1 seizure?

Answer 50

—Antiepileptic drug (AED) is usually not indicated after a first seizure with normal EEG and no risk factors

Question 51

How many healthy people with 1 seizure go on to develop a seizure disorder?

Answer 51

—Multiple studies have been done to determine what per cent of healthy patients with one unprovoked seizure will go on to have a second seizure:

1. A wide range of results, @29% - @61% but most are under 50%

—However, other studies show that once a healthy patient has had a SECOND UNPROVOKED SEIZURE, approximately 80% or more of these patients WILL go on to have more seizures

—So, this meets our definition of epilepsy, and patients should take a medication

Question 52

When should AEDs be considered?

Answer 52

—May consider initiation of AED after a first seizure with normal EEG if risk factors are present: abnormal MRI scan, a type of seizure which is known to recur, brain hemorrhage or tumor, even after surgical removal, etc.

Question 53

How common are seizure disorders overall?

Answer 53

—The latest surveys show that ultimately 3% of Americans will develop epilepsy, including the very elderly who are probably underdiagnosed

—Roughly three times this number of people have one or more provoked seizures

—Discuss safety measures when a seizure does occur - remove patients from harm

Question 54

What is the most common damage from seizures? How do most seizures end?

Answer 54

—The most common “damage” from seizures is trauma from falling, including fractures, or aspiration of gastric or oral contents, or biting the tongue or cheek

—Well over 90% of seizures end in two minutes or less, and no damage is done to the brain

Question 55

Should benzos be given IV to a person in a seizure?

Answer 55

—Do NOT give intravenous benzodiazepines (lorazepam, diazepam or others) unless there is status epilepticus which we will discuss later

1. These drugs have a much greater chance of causing respiratory arrest (perhaps over 5%) than the seizures do

Question 56

What are pseudoseizures?

Answer 56

—Some patients may unconsciously or deliberately have episodes which may appear to be seizures

—Now more often referred to as Psychologic Nonepileptic Seizures, or PNES

—Most of these patients have serious psychiatric illnesses, from conversion disorders to malingering, borderline personality disorders, history of physical and sexual abuse

Question 57

What do pseudoseizures look like?

Answer 57

—Look like generalized seizures, usually but with atypical features:

Asynchronous limb movements, eyes are often closed, involve pelvic thrusting or odd movements of the trunk, go on for more than 2 minutes, come on more slowly than typical seizures, do NOT respond to epilepsy drugs

Question 58

How are drugs for seizure disorders prescribed?

Answer 58

—If at all possible, use a single dug, pushing it to as high a dose as the patient can be comfortable with

—Laboratory “drug levels” can help this process, but should NOT be used too rigidly

—Some patients will need to gradually switch to a second drug, or take two drugs simultaneously, which may cause significant drug to drug interactions

Question 59

When should Rx for seizures be reevaluated?

Answer 59

—If a patient continues to have seizures after the use of three different anticonvulsants, at high doses, the physician needs to reevaluate:

—1. Does the patient truly have epilepsy?

—2. Is the patient noncompliant with the medication?

—3. Is the medication wrong for the apparent type of seizure?

Question 60

How good is control of seizure disorders with Rx?

Answer 60

—Most patients will have good control of their seizure frequency with a medication, especially patients with the generalized epilepsies

—Patients with partial epilepsies tend to be more difficult to control

—But what the physician considers “good control” may still be difficult for patients to cope with

Question 61

In addition to seizure control, what else should a physician be aware of with Rx?

Answer 61

—Choose an anticonvulsant drug appropriate for the type of seizure your patient has, and also consider the patient’s other illnesses or symptoms

—Also be aware of the possible adverse effects of these drugs

Question 62

When is surgery for seizures indicated?

Answer 62

—Requires extensive study of patients who have failed drugs, and who do NOT have pseudoseizures

—Multiple EEGs, including continuous video-EEGs for days in an Epilepsy Monitoring Unit

—If a definite focal source of the electrical discharges can be found, commonly in one of the temporal lobes, surgical excision is often safe and highly effective

—The majority of well-chosen patients for epilepsy surgery will no longer have to take anticonvulsants

Question 63

What is a vagal nerve stimulator?

Answer 63

—The Vagal Nerve Stimulator is one of perhaps many devices that will detect and try to stop seizures at their onset with strong electrical shocks

Question 64

What is status epilepticus?

Answer 64

—Defined as either multiple seizures without regaining of a normal level of consciousness between each one

OR:

—One prolonged generalized seizure for 30 minutes

(partial seizures lasting this long are NOT dangerous)

Question 65

Is status epilepticus a medical emergency?

Answer 65

—A true medical emergency which can be fatal if not treated

—30 minutes of seizing may cause permanent brain damage or the lack of respiration may cause death immediately

Question 66

What is the Tx for status epilepticus?

Answer 66

Treatment involves the usual “ABCs,” checking glucose and oxygen levels, and sometimes urine for toxicology studies

Administer small doses of lorazepam or diazepam, ONLY for status epilepticus, and not for a single seizure, and give a loading dose of phenytoin or another anticonvulsant(s)

—1. Be certain that the patient actually HAS status epilepticus, and not something else, including psychogenic seizures, or a movement disorder such as dystonia, tremors, chorea, etc.

—Stabilize in the usual manner: Airway, Breathing, Circulation

—An intravenous line is almost always necessary, except for the use of intramuscular phosphenytoin and diazepam (Valium)

—Give intravenous glucose if there is ANY chance of hypoglycemia, and oxygen if there is ANY chance of hypoxia