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Senior - E Med > 5 - Seizures > Flashcards

5 - Seizures Flashcards

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1
Q

Do pts with epileptic EEG’s always have symptoms?

A

Nope some are asymptomatic

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2
Q

Looks like a seizure but not a true seizure?

A

Some seizure-like episodes may be due to causes other than abnormal brain electrical activity, such attacks are not true seizures

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3
Q

What is epilepsy?

A

Clinical condition where individual is subject to recurrent seizures

More excitable brain with lower seizure threshold

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4
Q

Recurrent seizures but not an epileptic?

A

If the cause is a reversible condition i.e. etoh withdrawal, hypoglycemia, or other metabolic problem

This is not a seizure

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5
Q

Primary vs secondary seizure?

A

Primary/idiopathic: no known cause

Secondary/symptomatic: ID’d condition like mass lesion, previous head injury, or stroke

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6
Q

Reactive seizure?

A

Reaction to something bad like:

  • convulsant drugs
  • metabolic disturbance
  • sharp blow to head
  • etc

Cause seizure in otherwise normal person

Usually self limiting

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7
Q

Provoked and unprovoked seizure?

A

Provoked:
- Acute precipitating event w/in 7 days

Unprovoked:
- some guy just breaks in and pees on your rug

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8
Q

Status epilepticus?

A

Status epilepticus: seizure >5min or 2+ seizures w/out regaining consciousness

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9
Q

Refractory status epilepticus?

A

Refractory status epilepticus: persistent seizure activity despite IV admin of 2 antiepileptic agents

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10
Q

Types of Generalized seizures?

A

Tonic-clonic (grand mal)

Absence (petit mal)

(Consciousness is always lost)

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11
Q

Partial (focal) seizure?

A

Simple (no LOC)

Complex (consciousness impaired)

Partial w secondary generalization (jackson march)

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12
Q

“Other” seizures?

A

Myoclonic

Tonic

Clonic

Atonic

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13
Q

What is a jackson march or jacksonian seizure?

A

Only occurs on one side of body; progresses in a predictable pattern from twitching or tingling sensation or weakness in finger, big toe, or corner of mouth, then “marches” over a few seconds to entire hand/foot/face

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14
Q

What part of the brain is involved during a generalized seizure?

A

It is thought to be nearly simultaneous activation of the entire cerebral cortex

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15
Q

Generalized seizures begin with?

A

Abrupt loss of consciousness, may be the only clinical manifestation (absence attacks)

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16
Q

tonic-clonic (grand mal) seizure phases

A

Tonic phase: pt gets rigid
- trunk and extremities extend an pt falls to ground

Clonic phase: coarse trembling that evolves into symmetric rhythmic jerking of trunk and extremities

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17
Q

Describe grand mal seizure

A

Move seizure

  • Tonic phase followed by clonic phase
  • Pt is usually apneic/cyanotic
  • urination
  • vomiting
  • pt becomes flaccid and unconscious
  • deep rapid breathing
  • consciousness returns with postictal confusion and fatigue
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18
Q

How long does grand mal seizure usually last?

A

Generally 60-90 sec, though bystanders usually overestimate the time

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19
Q

Describe generalized absence (petit mal) seizure

A

Very brief (seconds)

  • sudden altered conscious
  • no change in postural tone
  • appear confused, detached or withdrawn
  • twitching of eyelids

may not respond to voice and loqse consciousness

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20
Q

Post petit mal?

A

Attack ceases abruptly and pt typically resumes what they were doing

No postictal symptoms

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21
Q

Classic generalized absence seizure pt?

A

School-aged children
- parents/teachers think they are daydreaming or not paying attention

Can occur up to 100 times/day

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22
Q

Prognosis for petit mal seizure?

A

They generally resolve as pt gets older

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23
Q

Generalized absence seizure in adults?

A

Probably not, more likely minor complex partial seizure and should not be termed absence

This matters b/c tx is different

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24
Q

Partial (focal) seizure?

A

Begin in a localized region of brain

May remain there or move and mimic generalized seizure

Can be bad enough that an EEG is required to differentiate

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25
Focal seizures symptoms and locations Motor cortex Occipital focus Medial temporal lobe
Motor: Unilateral tonic or clonic moments limited to one extremity Occipital focus: visual symptoms Medial temporal: bizarre olfactory or gustatory hallucinations
26
Initial symptoms of attacks?
Sensory phenomena, known as auras, are often the initial symptoms of attacks that then become more widespread, termed secondary generalization
27
Complex focal seizure?
Focal seizure where consciousness or mentation is affected Often caused by focal discharge in temporal lobe
28
Partial (focal) complex seizures are also commonly referred to as?
Temporal lobe seizures
29
Complex focal seizures are often misdiagnosed as?
Psych problems
30
Symptoms of complex focal seizure?
- Automatisms - Visceral symptoms - Hallucinations - Memory disturbances - Distorted perception and affective disorders I.e. “weird stuff” pill rolling, repetitive movements etc
31
automatisms?
Lip smacking Fiddling with clothing Repeating short phrases unconscious behaviors
32
Visceral symptoms with partial/focal seizures?
“Butterflies” rising up from epigastrium
33
Psychiatric symptoms of partial/focal seizures include fear, paranoia, depression, elation or ecstasy, this led to them being called?
Psychomotor seizures Name is no longer preferred as it causes confusion
34
1st step in doing a hx for a seizure?
Determine if it was actually a seizure Get through history and witness descriptions
35
Specific symptoms that help ID seizures?
``` Aura’s Abruptness of onset The progression of motor activity Loss of bowel/bladder Oral injury Localized or Generalized movements Unilateral or symmetric ``` Duration of symptoms Postictal confusion/lethargy
36
If the pt is a known epileptic you should?
Clarify the baseline seizure pattern Compare this one to the baseline ID the precipitating factors
37
Common precipitating factors?
- missing meds - alterations in meds - sleep deprivation - infection - exercise - electrolyte disturbance - ETOH/substance use/withdrawl
38
Indications of previous unwitnessed seizures?
- unexplained injuries, - nocturnal tongue biting - enuresis
39
Chart on
Slide on 26 has secondary seizure causes
40
Initial exam post seizure should look for?
Should focus on checking for injuries Posterior shoulder dislocation is easily overlooked
41
Besides checking for injuries the PE must also include?
Complete neurologic exam and subsequent serial exams Track the LOC
42
Todd’s paralysis?
Transient focal deficit (unilateral) following a simple/complex focal seizure Usually resolves w/in 48hrs
43
Symptomsm that help clue you into seizures over seizure mimicking conditions?
Abrupt onset/termination Lack of recall Purposeless movements Postictal confusion/lethargy
44
DDx syncope signs?
Prodrome: lightheadedness, diaphoresis, nausea and tunnel vision Cardiac syncope No postictal symptoms
45
Pseudoseizures?
``` Psychogenic seizures often associated with: conversion disorder, panic disorder, psychosis, impulse control disorder, munchausen syndrome or malingering ``` Often bizarre and highly visible
46
Symptoms of pseudoseizure?
Able to protect self from noxious stimuli Side to side head thrashing Rhythmic pelvic thrusting Clonic extremity motion that are alternating rather than symmetric May stop on command
47
Pseudoseizures will not have? (Diagnostic studies)
Positive EEG Lactic acidosis Elevated prolactin level
48
Another condition that is frequently preceded by aura?
Migraine MC aura is scintillating scomotoma
49
Labs you should order for seizure pts?
Well documented epileptics: - glucose - pertinent anticonvulsant med level New onset seizure: - glucose - BMP - lactate - calcium - Mg2+ - pregnancy - toxicology studies
50
Common lab findings with seizures?
Lactate-driven, wide anion gap metabolic acidosis - usually clears w/in 30 min Prolactin elevated for 15-60 min
51
Seizure imaging?
Head CT (1st seizure) to look for structural lesion X-ray: - injury - primary/metastatic tumor Any radiographs needed for injury diagnosis
52
LP for seizures?
If pt has acute seizure and is - febrile - immunocompromised - subarachnoid hemorrhage is suspected (with normal CT)
53
EEG for seizure?
Great for diagnosis but not really an ED thing If they symptoms are persistent get them to neuro
54
Uncomplicated seizure acute care?
Supportive - turn head to side - stay out of the way We dont usually need to ventilate or give meds during uncomplicated seizure
55
Uncomplicated seizures that last more than 5 min?
This is Status epilepticus; need more aggressive interventions
56
What usually causes seizures in epileptics?
They dont take their meds
57
1st unprovoked seizure, how long are you getting admitted for?
Jk the guidelines recommend not admitting these patients as long as: - normal neuoro - no comobidities - normal diagnostic testing - normal mental status
58
Anticonvulsants for 1st seizure?
Again no, not for the 1st one But if we need to give meds, we can defer anti-epileptic meds to the outpatient setting pending further studies, EEG and MRI
59
What about 2nd seizure?
Now you’re getting admitted
60
Recommendations for pts with 1st seizure?
Dont go swimming or work on electrical systems No driving (this is not a choice) until cleared by neurologist or primary care physician
61
Why are HIV pts more prone to seizures?
This commiunity has more incidence of: - Mass lesions - encephalopathy - herpes zoster - toxoplasmosis - cryptococcus - neurosyphilis - meningitis All of which increase likelihood of seizures
62
HIV pt has seizure, what tests are required?
Non-contrast CT if negative then do a lumbar puncture to look for CNS infection If still nothing is found get a contrast enhanced head CT or MRI
63
Women beyond 20 weeks of gestation with seizures in the presence of hypertension, edema, proteinuria is known as?
Eclampsia
64
Tx for eclampsia?
Magnesium sulfate >50% reduction in recurrence of seizures and lower incidence of pneumonia, ICU admission and assisted ventilation (When compared to diazepam and phenytoin)
65
Why are alcoholics more likely to get seizures?
- Withdrawl - missed meds - sleep deprivation - more head injuries - toxic co-ingestion - electrolyte abnormalities
66
Benzo’s and alcoholic seizures?
Benzo’s used to manage withdrawal symptoms will also prevent seizures - But the doses required are very large and given in escalating fashion
67
You have to already have epilepsy to get status epilepticus right?
False - can be your fist time (Did i just sound like a DARE class right there? Weed can kill you, even if you dont take it!!!! Dun dun duuuunnnnn)
68
MC causes of status epilepticus?
- subtherapeutic antiepileptic levels - preexisting neuro conditions - CNS infection - Trauma - hemorrhage - stroke - anoxia/hypoxia - metabolic abnormalities - ETOH/Drugs (intoxication or withdrawal)
69
Epilepsia partialis continua?
Focal tonic-clonic seizure activity with normal alertness that MC affects the distal leg or arm
70
What is nonconvulsive status epilepticus?
Seizure in the brain but not in the body The patient is comatose or fluctuating abnormal mental status or confusion but no overt seizure activity is present
71
Findings that suggest nonconvulsive status epilepticus?
Prolonged post-ictal period after generalized seizure Subtle motor signs (twitching, blinking) Fluctuating mental status Unexplained stupor or confusion in elderly
72
Tx for status epilepticus?
IV lorazepam: 2mg (0-.1mg/kg max) Or IV diazepam 10-20mg + 1 of the following - fosphenytoin: 20PE/kg at 150mg/min - phenytoin: 20mg/kg at 50mg/min - levtriacetam: 2000-4000mg
73
Tx for refractory status epilepticus?
Tx Goal is <30 min IV midazolam (o.2 mg/kg loading then 0.05-2mg./kg/hr ``` Or IV propofol (1mg/kg, then 1-10mg/kg/hr; or ketamine 5mg/kg.hr) ``` Or IV phenobarbital 20mg/kg at 50-75mg/min
74
Other than meds what is a refractory status epilepticus pt getting?
Intubation Neuro ICU admission Continuous EEG monitoring
75
Phenytoin cannot be given with?
Glucose containing solutions, must be given with normal saline
76
What type of paralytic agent is preferred for intubation?
A short acting one, we dont want to mask the ongoing seizure activity
77
Dont forget to check for ___ with status epilepticus?
Glucose
78
If bacterial meningitis or encephalitis is the suspected cause you should?
Give empiric antibiotic or antiviral therapy Dont do a LP!!!
79
Status epilepticus can induce what fluctuations in labs?
Brief peripheral leukocytosis CSF pleocytois (increased WBC)
80
Radiology for status epilepticus?
No, they cant get them while seizing
81
Lorezapam and diazepam doses for status epilepticus?
Lorazepam 2-4mg Diazepam 5-10mg Equally effective
82
Big difference between lorazepam and diazepam?
Lorazepam has slightly slower onset (3 min, valium is 2) but the duration is much longer (12-24hrs vs 15-60 min) and has fewer recurrences
83
DOC for status epilepticus?
IV lorazepam Works better than phenytoin or phenobarbital as initial drug
84
Drugs for established status epilepticus?
You follow the benzos with longer acting drugs - fosphenytoin - phenytoin - levetiracetam - valproate - lacosamide
85
Loading dose for fosphenytoin?
20 PE/kg infused at 150 PE/min over 10-15 min Or give it IM
86
Why dont we like valproic acid?
It works well but it has a black box for hepatic failure and pancreatitis Cannot be given with phenytoin
87
This drug is not approved by FDA but is rapidly becoming the first line for established status epilepticus
What is levetiracetam?
88
Current recommendations for status epilepticus refractory?
If after 2 anticonvulsants and 60 minutes you cant fix them then we give: Propofol Midazolam Barbituates (phenobarb or pentobarb) And possibly HOTN meds to fix the side effects of this coctail
89
SE refractory propofol dose?
2-10mg/kg/h titrated up to seizure cessation Short 1/2 life so can be dc once they stop
90
What is the risk of high dose propofol?
>40mg/kg/h pts are at increased risk for hemodynamic instability - HOTN - propofol infusion syndrome
91
What is midazolam and what is the dose?
Its a benzo Start at 0.05 - 0.4mg/kg/h and titrate up till they quit twitching
92
3rd line drugs for SE refractory?
Barbituates - phenobarbital: 20mg/kg/IV - pentobarbital Ketamine - bolus 0.5-4.5mg/kg - infusion of 5mg/kg/h May be considered but watch for respiratory depression and HOTN
93
PVT Joker: I looked forward to meet interesting and stimulating people from a ancient culture...
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Senior - E Med (8 decks)

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