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DC Flashcards > Ch 88-Seizures > Flashcards

Ch 88-Seizures Flashcards

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1
Q

What percent of adults experience at least 1 seizure? what percent will be diagnosed with epilepsy?

A

seizure- 10%
epilepsy- 3%

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2
Q

Define Seizure

A

A seizure is a sudden change in behavior caused by electrical hypersynchronization of neuronal networks in the cerebral cortex. (UTD)

Seizures are excessive excitatory neuronal activity associated with hypersynchrony of neighboring cells, resulting in sensory, motor, autonomic, or cognitive function alterations (Rosens 10th edition)

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3
Q

Define convulsions

A

refers specifically to the motor manifestations of a seizure

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4
Q

Define ictal period and post ictal period

A

The ictal period is the time
during which a seizure or seizure-like
activity occurs.

A postictal period
is an interval of transient neurologic dysfunction (commonly AMS or weakness) immediately following a seizure, generally lasting < 1 hour.

Longer ictal activity is associated with more
prominent and prolonged postictal symptoms

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5
Q

How are seizures classified?

A
  1. Primary seizure- unprovoked vs Acute symptomatic seizure - provoked (secondary)
  2. Generalized vs focal vs unknown onset
  3. Convulsive vs non-convulsive
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6
Q

Define status epilepticus

A

> 5 min of continuous seizures
2 discrete seizures with incomplete recovery between seizures
convulsive vs non-convulsive (dx on eeg)

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7
Q

Define epilepsy

A

The International League Against Epilepsy defines epilepsy as a
(A) diagnosis of epilepsy syndrome (e.g., juvenile myoclonic epilepsy, Lennox-Gastault
syndrome, benign rolandic epilepsy, infantile spasms);
(B) two or more seizures occurring more than 24 hours apart without an identified trigger;
(C) one unprovoked seizure coupled with
a higher likelihood of recurrent seizures over the subsequent decade

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8
Q

Define Primary vs secondary seizures

A

Primary- unprovoked
Secondary- provoked (acute symptomatic seizure caused by underlying pathophysiologic process

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9
Q

Define generalized vs focal seizures

A

Generalized- abnormal neuronal activity in both hemispheres (LOC or aLOC)

Focal Seizures-occur in one hemisphere>patient maintains consciousness

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10
Q

How are generalized seizures categorized?

A

Motor
-tonic clonic
-myoclonic
-atonic
-tonic
-clonic
-myoclonic-tonic-clonic
-myoclonic-atonic
-epileptic spasms

Non-motor (absence)
-typical
-atypical
-myoclonic
-eyelid myoclonia

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11
Q

How are focal seizures classified

A

Aware vs impaired awareness

Motor onset:
-autospasms
-atonic
-clonic
-epileptic spasms
-hyperkinetic
-myoclonic
-tonic

non-motor onset
-autonomic
-behaviour arrest
-cognitive
-emotional
-sensory

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12
Q

Triggers of breakthrough seizures in epilepsy

A

sleep deprivation
emotional or physical stress
menses
illness
medication change or non compliance

**still considered unprovoked

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13
Q

Most common cause of SE and new epilepsy in the elderly?

A

cerebrovascular disease

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14
Q

Define NORSE

A

new onset refractory status epilepticus

Pts without a known diagnosis of epilepsy or clear triggers (absent toxic exposure, metabolic derangements, or structural brain injury) presenting with denovo refractory status epilepticus

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15
Q

Define FIRES

A

subcategory of NORSE to specify subset of patients with clear prodrome of febrile illness for 24hr up to 2 weeks prior to SE presentation

FIRES is common (but not exclusive to) pediatric population

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16
Q

List 10 causes of seizures and status epilepticus in adults (Rosens Box 88.1)

A

Box 88.1

  1. Autoimmune
    -AI encephalitis
    -CREST, Goodpasture syndrome, SLE
    -MS
    -TTP
    -Acute disseminated encephalomyelitis (AEDM)
  2. Cerebrovascular disease
    -CVA
    -AVMs
    -CVST
    -ICH
    -SAH
    -PRES
    -RCVS
  3. Dementias
    - alzheimers
    -fronto-temporal dementia
    -vascular dementia
  4. Genetic syndromes & structural abnormalities
    - Focal cortical dysplasia
    -hydrocephalus
    -metabolic disease
    -mitochondrial disease
    -Porphyria
    -Tuberous scelrosis complex
    -wilsons disease
  5. Hypoxic ischemic brain injury
  6. Intracranial tumour
    -gangliogliomas
    -gliomas
    -lymphoma
    -meningioma
    -metastases
    -neuroectodermal tumor
  7. Metabolic
    - acidosis
    -elevated BUN
    -hypo/hyperglycemia
    -hyperammonia
    -hyper/hyponatremia
    -hypocalcemia
    -hypomagnesemia
    -wernicke encephalopathy
  8. Medications
    -EtOH and WD
    -alkylating agents
    -baclofen toxicity and WD
    -benzo WD
    -CAR-T
    -Carbapenums
    -cephalosporins (cefipime)
    -cylosporins
    -digoxin
    -fentanyl
    -heavy metals
    -lidocaine
    -metronidazole
    -tramadol
    -tacrolimus
    -subtherpeutic anti seizure meds
  9. Systemic disease
    -AoC renal failure
    -cirrhosis
  10. Trauma
    subdural/ epidural hematoma
    -SAH
    -DAI
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17
Q

Define ictal asystole

A

syndrome of focal epilepsies with left temporal onset, in females with PMHx of heart condition

ictal asystole lasting longer than 30 seconds is associated with
extra-temporal
seizure focus and secondary generalized tonic-clonic
seizures.

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18
Q

Most common cause for ED presentation of recurrent seizures

A

medication non compliance

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19
Q

List common causes of adult onset focal seizures in low and middle countries

A
  1. neurocysticerosis
  2. malaria
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20
Q

List 10 potential systemic complications related to seizures and status epilepticus

A
  1. Cardiac
    - arrhythmia’s
    - cardiac arrest
    - CM
    - HTN
    - thermodysregulation
  2. MSK
    -fracture/dislocation
  3. GI
    -hepatotoxicity and pancreatitis
    -ilieus and bowel ischemia
  4. Heme
    - rhabdo
    -leukocytosis/leukopenia
    -thrombocytopenia
  5. Pulmonary
    -AW obstruction
    -apnea/hypoventilation
    -aspiration
    -hypoxia
    -mucous plugging
    -pulmonary edema
  6. Renal/acid-base
    - ARF
    -Acidosis -lactic, respiratory
    -Hyperglycemia
    -hyperkalemia
    -myoglobinuria
  7. Prolonged ICU course complications
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21
Q

How to manage seizure caused by hyponatremia

A

Hypertonic saline (3%)
adult- 100 ml 3% NaCl / 10 min

children- 2-5ml/kg (up to 150 ml) over 20 min

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22
Q

How to manage seizures caused by hypocalcemia

A

calcium chloride or gluconate amps until seizure aborts

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23
Q

How to manage seizures caused by TCA OD

A

sodium bicarb
1 to 2 mEq/kg IV bolus; repeat as needed to maintain ECG QRS complex ≤ 100 msec

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24
Q

How t manage seizures caused by salicylate OD

A

Sodium bicarb or HD
Administer 1 to 2 mEq/kg IV bolus; repeat as needed to maintain a blood pH of 7.4 to 7.5

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25
How to manage seizures caused by isoniazid toxicity
Pyridoxine 5 g IV (adult) or 70 mg/kg (pediatric)
26
How to manage seizures caused by lithium toxicity
HD
27
How to treat seizures caused by sympathomemetics/EtOH WD/ MDMA
Benzodiazepines
28
How to treat seizures caused by eclampsia
Magnesium sulfate IV loading dose of 4 to 6 g over 15 to 20 minutes, then 1 to 2 g/h infusion; monitor patients for hyporeflexia; alternatively, lorazepam (Ativan) 4 mg IV over 2 to 5 minutes or diazepam (Valium) 5 to 10 mg IV slowly can be used to terminate the seizure, after which magnesium sulfate is administered
29
Seizure + HTN+ bradycardia are suggestive of what intracranial pathology
herniation syndromes
30
What are proposed seizure triggering thresholds for the following metabolic derangements: Glucose, sodium, calcium, magnesium, BUN, creatinine
Glc <2.0 or >25 Na <115 Ca <1.2 Mg <0.3 BUN >35.7 creatinine >884
31
When do early post traumatic seizures typically occur? how many of those occur in the first 24h
Early post-traumatic seizures occur within the first week, with over 50% occurring within the first 24 hours
32
Describe post traumatic seizure prophylaxis
Early post-traumatic seizures occur within the first week of initial brain insult, with over 50% occurring within the first 24 hours. Guidelines recommend 7 days in traumatic brain injury and short-term therapy in subarachnoid hemorrhage.
33
How are seizures in pregnancy classified
1. Diagnosed epilepsy + pregnant 2. new onset seizure in pregnant pts 3. seizure 2/2 to eclampsia
34
Define recruitment as it relates to seizure development and progression
Defined as the activation of neurons by increased electrical activity of adjacent neurons. Neuronl impulses that track into deep circuits of the subcortex (ie RAS) or cross the midline cause alterations in LOC. The process of recruitment explains seizure auras (i.e., alterations in sensation, autonomic deregulations, aphasia, deja vu, lip smacking, repeated swallowing, picking at clothing secondary to abnormal neuronal activity) and how focal seizures can secondarily become generalized
35
List 4 clinical findings that differentiate seizures from syncope
Features of Seizure: 1. Post ictal state 2. Longer duration of motor manifestations 3. loss of bladder/bowel control 4. tongue biting or laceration Features of syncope 1. rapid recovery/ spontaneous return of conciousness 2. less likely to have motor involvement, if present lasts seconds 3. no loss of bladder/bowel function 4. No tongue biting
36
List 5 features that differentiate neurogenic and psychogenic seizures
Features of PNES - often longer in duration compared to neurogenic -recollection of events during psychogenic seizure - forward thrusting pelvic movements -head turning from side to side during event -gaze deviation away from examiner during event -avoid noxious stimuli during event -typical metabolic acidosis not present after event
37
List 5 diagnosis that can mimic seizures
Cardiac 1. Vasodepressive (vagal) syncope 2. Orthostatic syncope 3. Cardiogenic syncope Neurologic 1. Stroke, transient ischemic attack 2. Atypical migraine 3. Movement disorders 4. Mass lesions Toxicologic 1. Intoxication, inebriation 2. Oversedation, over-analgesia 3. Extrapyramidal symptoms Metabolic 1. Hypo-, hyperglycemia 2. Thyrotoxicosis 3. Delirium tremens Infectious 1. CNS infections 2. Tetanus Psychiatric 1. Pseudoseizure 2. Panic attacks 3. Cataplexy
38
List 10 causes of status epilepticus in adults (crack cast)
Metabolic Disturbances 1. Hepatic encephalopathy 2. Hypocalcemia 3. Hypoglycemia or hyperglycemia 4. Hyponatremia 5. Uremia Infectious Processes 1. Central nervous system abscess 2. Encephalitis 3. Meningitis Withdrawal Syndromes 1. Alcohol 2. Antiepileptic drugs 3. Baclofen 4. Barbiturates 5. Benzodiazepines Central Nervous System Lesions 1. Acute hydrocephalus 2. Anoxic or hypoxic insult 3. Arteriovenous malformations 4. Brain metastases 5. Cerebrovascular accident 6. Eclampsia 7. Head trauma: acute and remote 8. Intracerebral hemorrhage 9. Neoplasm 10. PRES Intoxication 1. Bupropion 2. Camphor 3. Clozapine 4. Cyclosporine 5. Flumazenil 6. Fluoroquinolones 7. Imipenem 8. Isoniazid 9. Lead 10. Lidocaine 11. Lithium 12. MDMA 13. Metronidazole 14. Synthetic cannabinoids 15. Theophylline 16. Tricyclic antidepressants
39
Outline the management of SE in the pre hospital setting
Assess ABCs Attach monitors -Pulse oximetry ECG BG- treat if low Place pt in position of safety (left lateral decubitus) Give one of the following medications: - Midazolam 10 mg IV/IM/IN - FIRST LINE IF NO IV - Lorazepam 2 mg up to max of 10 mg IV - FIRST LINE IF IV - Diazepam 5 mg up to max of 20 mg PR - do not use re: poor absorption
40
Outline the management of SE in the ED
1. Ongoing seizure activity: -Midazolam 10 mg IV/IM/IN - FIRST LINE IF NO IV - Lorazepam 2 mg up to max of 10 mg IV - FIRST LINE IF IV AND (Keppra first line) - Phenytoin 20 mg/kg IV at max rate 50 mg/min - Fosphenytoin 20 PE/kg IM or IV at max rate of 150 mg/min - Valproic Acid 20-40 mg/kg at 3-6 mg/kg/min - Keppra 1000-3000 mg over 15 minutes If seizure still not aborted - Intubation and EEG recommended - Treat with one of the following third-line medications: - Phenobarbitol 20 mg/kg IV at 50-75 mg/min - Midazolam 0.2mg/kg IV, then 0.1-0.4 mg/kg/hr - Propofol 2 mg/kg IV at 2-5 mg/kg/hr, then 5-10 mg/kg/hr as needed
41
Diazepam dosing for seizure in adult and peds
Adult 5 mg IV, up to max 20 mg or 10-20 mg PRN Peds 0.2-0.5 mg/kg IV/ET or 0.5-1.0 mg/kg PR (max 20 mg) May repeat in 10 minutes; monitor respiratory status
42
Lorazepam dosing for seizure in adult and peds
Adult- 2 mg IV at 2 mg/min, up to max 10 mg IV Peds- 0.05-0.1 mg/kg IV (max 2 mg) Preferred IV benzo; may repeat in 10 minutes; monitor respiratory status
43
Midazolam dosing for seizure in adult and peds
Adult- 5 mg, up to a max of 10 mg IV/IM/IN Peds-0.2 mg/kg IV/IM/IN (max 5 mg) Preferred IM benzodiazepine; may repeat in 10 minutes; monitor respiratory status
44
List 10 indications for CT head for first seizure
- New focal deficit - Persistent altered mental status - Fever - Recent trauma - Persistent headache - History of cancer - Anticoagulant use - Suspicion or known history of AIDS - Age > 40 years - Presence of partial complex seizure
45
List 5 characteristics of ictal events
1. Abrupt onset: -History should focus on any evidence of an aura. 2. Brief duration. -Seizures rarely last longer than 90 to 120 seconds, Status epilepticus is the important exception. 3. Alteration of consciousness. -Generalized seizures are manifest by loss of consciousness; focal seizures are often accompanied by an alteration in consciousness. 4. Purposeless activity. -Automatisms and undirected tonic-clonic movements are common in ictal events. Tonic-clonic movements are rhythmic and generally do not involve head shaking. 5. Postictal state. -can last from minutes to hours, depending on which specific region of the brain triggered the seizure, seizure duration, age, and use of an antiepileptic drug (AED).
46
Name 3 metabolic causes of seizures
The top 6 metabolic abnormalities causing seizures are: 1. Hyponatremia 2. Hypocalcemia 3. Hypoglycemia 4. Hyperglycemia 5. Uremia 6. Hyperammonemia
47
What percentage of patients with convulsive status epilepticus will develop non-convulsive status epilepticus?
up to 15% of patients who are successfully treated for convulsive status epilepticus remain in non-convulsive status afterwards.
48
List 5 causes of persistent AMS in a patient who has seized
Metabolic- hypoglycaemic; encephalopathy CNS- ICH, migraine, Transient global amnesia Infectious Drug intoxication or WD Psychogenic
49
What is Todds Paralysis?
- Transient post-ictal paralysis - Common (13%) following focal motor seizure affecting one side of the body - Can also affect speech, gaze or vision - Usually subsides within 24hrs **high likelihood of underlying structural cause of seizure
50
List 4 features that increase the likelihood the event was a seizure
>45 yo Abrupt onset and brief duration Confirmed unresponsiveness Postictal confusion Rhythmic limb shaking or dystonic posturing Tongue biting Head or eye turning to one side Cyanosis Preceding déjà vu or aura NOTE Incontinence and trauma were not discriminative findings between seizure, syncope, and nonepileptic attack disorder..
51
List 8 causes of toxin-induced seizure
1. organophosphate 2. TCA 3. Salicylate 4. sympathomemetic 5. Camphor 6. Methylxanthine 7. Benzo WD 8. EtOH WD 9. lithium 10. lidocaine
52
Name 5 infectious causes of provoked seizures
Bacterial meningitis (s. pneumonia most common in adults, GBS in <2mo Viral encephalitis (HSV, EBV, enterovirus, west nile) Abscess (gram + strep and staph most common) syphillis cysticercosis Malaria
53
List 5 causes of seizure with immediate reversible treatment
Hyponatremia Hypoglycemia Hypocalcemia TCA ASA Isoniazide cocaine etoh lithium MDMA eclampsia
54
List 3 causes of seizure in HIV patients
1. Toxoplasmosis Clinical: Fever; HA; AMS; seizures; weeks Imaging: ring enhancing Dx: PCR for Toxo 2. Cryptococcous Clinical:Fever; HA; AMS; seizures Imaging: ring enhancing Dx: india ink 3. CNS lymphoma Clinical: fever; wt loss; sweats; months Imaging: ring enhancing Dx: PCR for EBV 4. PML Clinical: FND; ataxia; VF loss; months Imaging: demyelinatoin Dx: PCT for JC 5. HIV encephalopathy Clinical: depression, movement, memory Imaging: T2 signals Dx: PCR for HIV 6. CMV Clinical: FND; confusion Imaging: micronodules Dx: PCR for CMV 7. Abscess Clinical: Fever; FND; bacteremia Imaging: ring enhancing Dx: culture 8. TB Clinical: FND; TB SxS Imaging: Ring enhancing Dx: Culture
55
Phenytoin dosing
Phenytoin 20 mg/kg IV at max rate 50 mg/min
56
Fosphenytoin dosing
Fosphenytoin 20 PE/kg IM or IV at max rate of 150 mg/min
57
Valproic Acid dosing
Valproic Acid 20-40 mg/kg at 3-6 mg/kg/min
58
Keppra dosing
Keppra 1000-3000 mg over 15 minutes
59
phenobarbitol dosing
Phenobarbitol 20 mg/kg IV at 50-75 mg/min
60
Midazolam infusion dosing for third line therapay
Midazolam 0.2mg/kg IV, then 0.1-0.4 mg/kg/hr
61
Propofol infusion dose 93rd line)
Propofol 2 mg/kg IV at 2-5 mg/kg/hr, then 5-10 mg/kg/hr as needed
62
Carbamezipine loading dose and route of administration of AEDs when resuming in the ED
8mg/kg po suspension x1
63
Keppra loading dose and route of administration of AEDs when resuming in the ED
1500 mg po load or rapid IV up to 60 mg/kg
64
phenytoin loading dose and route of administration of AEDs when resuming in the ED
20 mg/kg divided into max doses of 400 mg q 2 h po. or 18 mg/kg IV at <50 mg/min
65
VPA loading dose and route of administration of AEDs when resuming in the ED
up to 30 mg/kg IV to max rate of 10 mg/kg/min
66
What anticonvulsants can paradoxically cause seizures in supratherapeutic levels?
Phenytoin Carbamazepine Valproic Acid Lamotrigine Therefore… if known to take Rx, give HALF loading dose (in case they are seizing because of supratherapeutic levels)
67
What options do you have for anti-epileptics if you can’t get IV access?
Midazolam IM, IN, Buccal Lorazepam SL (can also give IM) Diazepam PR
68
When would you consider starting a patient with first time seizure on an antiepileptic? What DC instructions will you provide
Decision to start on anticonvulsant based on: Risk of seizure recurrence – more common in partial seizures, status, hx, intracranial sx/trauma, presence of Todd’s paralysis Presence of any underlying predisposing disease – particularly HIV Have to consider risk of anticonvulsant tx – side effects and drug interactions In most cases, no need to tx after 1st unprovoked seizure Refer to neuro – let them decide PATIENT EDUCATION MOST IMPORTANT! d/c instructions: avoid swimming w/o lifeguard, don’t work w/ hazardous tools/equipment/ladders, report to driving agencies as required, document instructions precisely

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