Neuro Emergencies: Seizures Flashcards by Andrew Kreutzer

Acute Symptomatic Seizures can occur from the following?

Head Trauma
Brain Tumors
Intracranial Infection
Congenital brain malformations
Hypo/hyperglycemic
Hyper/hyponatremia
Hypocalcemia
Hypomagnesemia
Withdrawal states
Hypoxic brain injury
Stroke
Vascular malformations
Eclampsia
Hypertensive encephalopathy
Hyperthyroidism
Toxic/metabolic
AED non-compliance

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Differential Diagnosis for seizure like symptoms

Syncope
Tremors
Rigors
Nonepileptic seizures
Dyskinesia
TIA

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Types of Generalized Seizures

Convulsive
Absence
Tonic
Atonic
Myoclonic

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Types of Generalized Absence Seizures

Typical
Myoclonic Absence
With eyelid myoclonia
Atypical

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Types of Generalized Myoclonic Seizures

Negative Myoclonus
Myoclonic-Atonic

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A generalized seizure is conceptualized as originating at some point within, and rapidly engaging, bilaterally distributed networks
Can include cortical and subcortical structures, but do not necessarily include the entire cortex
Although individual seizure onsets can appear localized, the location and lateralization are not consistent from one seizure to another
Can be asymmetric
What type of Seizure?

Generalized

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Typically bilateral and symmetric although variants with asymmetry including head and eye deviation can be seen
A tonic clonic seizure is a seizure consisting of a tonic and a clonic phase, typically in this order, however variations such as clonic-tonic-clonic are also seen
A clonic seizure is a seizure involving bilaterally rhythmic jerking and may occur alone or in combination with tonic activity where there is bilaterally increased tone of the limbs typically lasting seconds to a minute
The jerking in a clonic seizure is more sustained and rhythmic than seen in a myoclonic seizure
What type of Seizure?

convulsive

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Seizure is a generalized seizure with abrupt onset and offset of altered awareness which can vary in severity
Memory for events during the seizures is usually impaired although there may be some retained awareness particularly for adolescents
Clonic movements of eyelids, head, eyebrows, chin, perioral or other facial parts may occur
Myoclonus of limbs can rarely occur
Oral and manual automatisms are common and there may be perseveration of behaviors occurring prior to seizure onset
Absence seizures were previously known as ‘petit mal’ seizures
Absence status epilepticus can occur
What type of Absence Seizure?

Typical

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Rhythmic myoclonic jerks of the shoulders and arms with tonic abduction that results in progressive lifting of the arms during the seizure
The myoclonic jerks are typically bilateral but may be unilateral or asymmetric
Perioral myoclonias and rhythmic jerks of the head and legs may occur
Seizures last 10-60 seconds and typically occur daily
Level of awareness varies from complete loss of awareness to retained awareness
What type of Absence Seizure?

Myoclonic Absence Seizure

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Absence seizures accompanied by brief, repetitive, often rhythmic, fast (4-6 Hz) myoclonic jerks of the eyelids with simultaneous upward deviation of the eyeballs and extension of the head
Seizures are typically very brief (<6s in duration) and multiple seizures occur on a daily basis
Mostly awareness is retained
What type of Absence Seizure?

Absence with eyelid myoclonia seizure

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Seizure has less abrupt onset and offset of loss of awareness than typical absence seizures
They are often associated with other features such as loss of muscle tone of the head, trunk or limbs (often a gradual slump) and subtle myoclonic jerks
Often occur in individuals with intellectual impairment
The loss of awareness may be minimal with the patient continuing an activity, but more slowly or with mistakes
What type of Absence Seizure?

Absence Atypical Seizure

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Involves bilaterally increased tone of the limbs typically lasting seconds to a minute
They often occur out of sleep and in runs of varying intensity of tonic stiffening
The individual is unaware during these events
At the beginning with more intense stiffening, individuals may make an expiratory sound
More severe and prolonged seizures may have a vibratory component which may be confused with clonic jerking
Often occur in individuals with intellectual impairment
What type of seizure?

Tonic Seizure

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Involves sudden loss or diminution of muscle tone without apparent preceding myoclonic or tonic features
Very brief (<2 seconds) and may involve the head, trunk or limbs
Often occur in individuals with intellectual impairment
What type of seizure?

Atonic Seizure

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A single or series of jerks (brief muscle contractions)
Each jerk is typically milliseconds in duration
Status epilepticus of this type is characterized by ongoing (> 30 minutes) irregular jerking, often with partially retained awareness
What type of Seizure?

Myoclonic Seizure

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Is a seizure with brief cessation of background muscle tone, lasting less than 500 milliseconds
The resulting movement produced can have two components, an initial loss of posture caused by the negative myoclonus, and a subsequent voluntary, compensatory movement to restore posture
May occur in isolation or in a series
What type of Seizure?

Negative Myoclonic Seizure

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Is a myoclonic seizure followed by an atonic seizure
Sometimes a series of myoclonic jerks occurs prior to the atonia
The head and limbs are affected, typically resulting in rapid fall
The myoclonic jerk may be subtle

Myoclonic-Atonic Seizure

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Focal Seizure features include

Aura
Motor
Autonomic
Dyscognitive

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Focal seizures are conceptualized as originating within

networks limited to one hemisphere

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Focal Seizures distribution may be?

discretely localized or more widely distributed

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Focal seizures may originate in

subcortical structures

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Focal Seizuers
For each seizure type, ictal onset is what?

with preferential propagation patterns that can involve what?

consistent from one seizure to another

the ipsilateral and/or contralateral hemisphere

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Focal seizures can be described by their

semiology (features)

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The features that occur may reflect the regional networks involved what?

often enabling what?

in the seizure origin or propagation

these areas of the brain to be identified

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Some features allow identification of what?

others allow identification of what?

the hemisphere involved

the discrete area of the brain (for example a lobe) that is involved

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Auras are subjective and may be?

sensory or experiential

Auras reflect the initial what?

seizure discharge

An aura may be an isolated phenomenon or progress to a focal seizure with

objective features (with or without altered awareness) or to a bilateral convulsion

An aura is also known as a?

Warning

A sensory aura involves what?

A sensation w/o an objective clinical sign

Characterized by sensory phenomena including tingling, numbness, electric-shock like sensation, pain, sense of movement, or desire to move occur in seizures involving the sensorimotor cortex

Somatosensory Aura

Characterized by elementary visual hallucinations such as flashing or flickering lights, spots or other shapes, simple patterns, scotomata, or amaurosis More complex hallucinations such as seeing formed images are considered experiential aura. Occur in seizures involving the occipital lobe, and are often colored in nature

Visual Aura

Characterized by elementary auditory phenomena including buzzing, ringing, drumming or single tones More complex hallucinations such as voices are considered experiential seizures Occur in seizures involving auditory cortex in the lateral superior temporal lobe

Auditory Aura

Characterized by phenomena - usually an odor, which is often unpleasant Occur in seizures involving the mesial temporal or orbitofrontal regions

Olfactory Aura

Characterized by taste phenomena including acidic, bitter, salty, sweet, or metallic tastes Occur in seizures involving the parietal operculum and the insula

Gustatory Aura

Characterized by upper abdominal phenomena including discomfort, emptiness, tightness, churning and a sensation that may rise up to the chest or throat Occur in seizures involving the mesial temporal lobe

Epigastric Aura

Characterized by a sensation in the head such as light-headedness or headache

Cephalic Aura

An experiential aura involves affective, mnemonic (memory) or perceptual subjective phenomena including depersonalization and hallucinatory events; these may appear alone or in combination Experiential aura include the following types

Affective Mnemonic Hallucinatory Illusory

Characterized by phenomena such as fear, depression, joy and anger.

Affective Aura

Characterized by memory phenomena such as feelings of familiarity (déjà vu) and unfamiliarity (jamais vu)

Mnemonic Aura

Characterized by imagined complex sensory phenomena that may involve visual (e.g. formed images), auditory (e.g. hearing voices) or other sensory modalities, without change in awareness The sensory phenomena may be accompanied by associated emotion or interpretation e.g. may be experienced as persecutory

Hallucinatory Aura

Characterized by an alteration of actual perception involving visual, auditory, somatosensory, olfactory, and/or gustatory phenomena, without change in awareness

Illusory Aura

A motor feature involves motor activity and may consist of Motor features may be?

an increase (positive) or decrease (negative) in muscle contraction elementary or complex

Involves a stereotyped contraction of a muscle or group of muscles. Such motor features may be predominantly convulsive (e.g. hemiclonic), myoclonic, tonic, epileptic spasm, versive or dystonic.

Elementary Motor

rhythmic jerking (clonic activity) that may occur alone or in combination with tonic activity

Convulsive Motor

a single or short cluster of brief muscle contractions (jerks)

Myoclonic Motor

increased muscle tone

Tonic Motor

sudden flexion, extension or mixed flexion-extension of proximal truncal muscles, lasting 1-2 seconds, typically occurs in a series

Epileptic spasm Motor

sustained, forced conjugate ocular, cephalic, and/or truncal rotation or lateral deviation from the midline

Versive Motor

sustained contractions of both agonist and antagonist muscles producing athetoid or twisting movements, may produce abnormal postures

Dystonic

involves complex movement patterns. Three types are recognized, hypermotor, negative motor and automatism.

Complex motor feature

Involves proximal limb or axial muscles, producing irregular large amplitude ballistic movements, such as pedaling, pelvic thrusting, jumping, thrashing and/or rocking movements

Hypermotor

Characterized by reduced motor activity

Negative Motor

Coordinated, repetitive motor activity usually occurring when cognition is impaired and for which the subject is usually amnesic afterward. This often resembles a voluntary movement and may consist of an inappropriate continuation of pre-ictal motor activity.

Automatism

Automatism Lip smacking, lip pursing, chewing, swallowing, clicking

Oroalimentary

Automatism Bilateral or unilateral distal or proximal movements, including fumbling, tapping, manipulating movements of hands or feet

Manual or pedal

Automatism Often unilateral, fumbling or exploratory movements with the hand intended to lend emotional tone to communication

Gestural

Automatism Bursts of laughter or giggling, usually without appropriate affective tone and described as 'mirthless’ This is characteristic of seizures arising in the hypothalamus, but can occur in seizures arising in the frontal or temporal lobes

Gelastic

Automatism Single or repetitive sounds such as shrieks or grunts

Vocal

Automatism Single or repetitive words, phrases or brief sentences

Verbal

Automatism Outbursts of crying

Dacrystic

Characterized by phenomena, which can involve cardiovascular, gastrointestinal, vasomotor, and thermoregulatory functions Examples include palpitations, nausea, butterflies, hunger, chest pain, urge to urinate or defecate, goosebumps, sexual sensation, feeling hot or cold, pilo-erection, pallor, tachycardia or bradycardia/asystole, flushing, pupillary changes and lacrimation What type of Focal Seizure Feature?

Autonomic

Involves altered awareness or responsiveness Degree of loss of awareness or responsiveness may vary What type of Focal Seizure Feature?

Dyscognitive

Old Guideline International League Against Epilepsy classification of seizures: Consciousness is not impaired Only part of the cortex is disrupted by the seizure

Simple Partial Seizures

Old Guideline International League Against Epilepsy classification of seizures: Abrupt loss of consciousness May stare or engage in repetitive behaviors

Complex Partial Seizures

Old Guideline International League Against Epilepsy classification of seizures: Usually occur in childhood Frequently occur in clusters Sudden staring with impaired LOC May have eye blinking or lip smacking

Absence or petit mal

Old Guideline International League Against Epilepsy classification of seizures: AKA Grand Mal seizure Abrupt loss of consciousness Muscles become stiff followed by jerking and twitching

Generalized tonic-clonic seizures

Old Guideline International League Against Epilepsy classification of seizures: Rhythmical jerking muscle contractions Usually involve the arms, neck and face

Clonic Seizures

Old Guideline International League Against Epilepsy classification of seizures: Sudden brief muscle contractions Occur singly or in clusters Consciousness usually not impaired

Myoclonic seizures

Old Guideline International League Against Epilepsy classification of seizures: Sudden muscle stiffening (falling to ground) Impaired LOC

Tonic Seizures

Old Guideline International League Against Epilepsy classification of seizures: Sudden loss of control of the muscles Usually of the legs

Atonic Seizures

Period following the seizure Recovery period for the brain May last minutes to hours

Postictal State

History Taking for Diagnostic purposes, ask about?

Epilepsy Recently d/c'd meds recreational drug use precipitating events aura seizures semiology incontinence tongue biting post ictal state

Physical Exam for Diagnostic purposes, look for?

Post ictal paresis eye deviation fluctuating LOC Observe for s/sx of NCSE

Diagnostic Tests that should be completed?

EEG LP

Imaging that should be completed?

CT or MRI

Laboratory studies that should be completed?

Blood glucose BMP Mg Phos CBC UA UDS AED levels

Laboratory studies specific to LP that should be completed?

Cell count glucose protein cultures

Predisposing factors for status epilepticus include?

AED noncompliance Withdrawal Syndromes Acute structural injury Metabolic abnormalities Drugs Anoxia

Status Epilepticus is defined as?

5 min or more of continuous clinical and/or electrographic seizure activity. Repetitive seizures without return to baseline between seizures

Most seizures stop within a few minutes Any seizure lasting > 5 minutes likely to evolve to what?

Status Epilepticus

Classification of Status Epilepticus Convulsions that are associated with rhythmic jerking of the extremities

Convulsive

Classification of Status Epilepticus “Wandering confused” patient Acutely ill patient with severely impaired MS with or without subtle movements

Non-convulsive

Classification of Status Epilepticus Status Epilepticus that has not responded to a Benzo and 1 AED

Refractory SE

Classification of Status Epilepticus Failed secondary treatment Anesthetic is usually required

Super Refractory SE

Lactic acidosis is what in SE? And usually is resolved how?

common early spontaneously once seizures are treated

Intubation usually required more due to?

toxicity of therapies administered to control seizures than due to ongoing seizures themselves

Alternatives to help keep airway patent? Monitor what?

Oral or nasal airways Sats, BP, and HR

Avoid what in SE management?

long-acting paralytics

What should always be checked with SE?

blood glucose

Emergent Medications Benzodiazepines that can be used/dose?

Lorazepam 0.1 mg/kg IV Diazepam 0.15mg/kg IV (can be given PR) Midazolam 0.2 mg/kg IM (up to 10 mg) (can be given buccal or intranasal)

Emergent Medications Fosphenytoin Dose? Check what? Advantage? Disadvantage?

20 mg/kg IV (at no more than 50 mg/min) Check post-load level and consider additional bolus No respiratory depression CV instability (bradycardia, hypotension)

Emergent Medications Valproic Acid Dose? Useful if? (4) Can be?

20-40 mg/kg IV (may give additional 20mg/kg) Patient allergic to phenytoin and/or phenobarbital High risk for CV instability (old, hypotensive, CVD) Already taking VPA with sub-therapeutic levels Generalized (or myoclonic) epilepsy Hepatotoxic

Emergent Medications Levetiracetam Dose? Useful if? (4)

30-60 mg/kg IV initial load (max dose 4500 mg) Patient allergic to phenytoin and/or phenobarbital High risk for CV instability (old, hypotensive, CVD) Already taking phenytoin with therapeutic levels Minimal drug interactions

Emergent Medications Phenobarbital Dose? Disadvantage?

20 mg/kg IV (may give additional 5-10 mg/kg) Respiratory depression and hypotension

Continuous infusions for RSE/SRSE Midazolam load with? maintenance? Re-bolus prior to? Goal of therapy? Higher doses may induce?

0.2-0.4mg/kg 0.1-3mg/kg/hr increasing seizure cessation Burst suppression

Continuous infusions for RSE/SRSE Propofol Load with? maintenance? Titrate how? Concern for?

1-2mg/kg bolus 1-10 mcg/kg/min up quickly Propofol infusion syndrome

Continuous infusions for RSE/SRSE Ketamine Load with? Maintenance?

1-2 mg/kg IV 1-10 mg/kg/hr

Continuous infusions for RSE/SRSE Pentobarbital Load with? Maintenance? Half-life is approx.?

5mg/kg 1-10 mg/kg/hr 20 hrs

When to use continuous EEG

Recent clinical seizure or SE without return to baseline Any patient in RSE on continuous drips While weaning drips Coma, including post cardiac arrest Epileptiform activity (PLEDs or GPEDs) on initial EEG Intracranial Hemorrhage (ICH, SAH, TBI) Suspected NCSE in patients with AMS Cessation of non-convulsive seizures

What % of pts remain unresponsive after successful cessation of convulsive SE still in SE?

14%

Why should we use EEG for pts in RSE on continuous gtt?

Allows titration to goal

When can continuous EEG be discontinued?

if off all anesthetics and no seizures for 24-48 hours

How to periodically reassess?

Spot EEG

What % of comatose patients, including post cardiac arrest, have NCSE?

20-60%

What % of patients with epileptiform activity (PLEDs or GPEDs) are at risk for NCSE?

40-60%

Duration of therapy for SE Continue achieved target (seizure control or burst-suppression) for? Wean infusions over? and observe EEG closely for? Optimize what? Success =?

24-48hrs 12-24 hrs; recurrence of seizures underlying maintenance regimen off gtts and seizure free > 24 hrs

Neuro Emergencies: Seizures Flashcards

(107 cards)