Seizure

Question 1

Seizure types:

Answer 1

Generalised
- Convulsive
–> Grand mal
- Non-convulsive
–> Absence
–> Tonic
–> Myoclonic
–> Atonic

Partial
- ‘Simple partial’- Consciousness/awareness preserved
- ‘Complex partial’- ALOC/ won’t respond

Question 2

Seizure mimics:

Answer 2

Pseudoseizure
Myoclonic syncope
Rigors
Movement disorder (eg. dyskinesia)
Sleep disorder
Migraine
TIA

Question 3

Features of PSEUDOseizure:

Answer 3

Head side to side
Pelvic thrusting
Avoid injury
Avoid gaze when eyes opened
No tongue biting/ incontinence
No post-ichtal state
No hypoxia during
Normal lactate

Question 4

List 3 medication options to treat seizure in someone without IV access:

Answer 4

PR diazepam (0.5mg/kg)
IM midazolam (0.3mg/kg)
IN midazolam (0.3mg/kg)
Buccal midazolam (0.5mg/kg)

…..IO!

Question 5

When should phenytoin be avoided for the management of seizure?

Answer 5

Toxocological, including alcohol (ineffective)

Question 6

STATUS EPILEPTICUS: definition

Answer 6

Continuous seizure activity for >5 minutes

2 or more seizures without neurological recovery in between

Question 7

STATUS EPILEPTICUS: Mortality

Answer 7

Managed early, only 3%.

Beyond 1 hour, 30%!!!!! - Emergency!!

Question 8

STATUS EPILEPTICUS: treatment

Answer 8

SEEK AND TREAT HYPOGLYCAEMIA
——-

1st- BZD
eg.
- IV: Diaz 0.3/kg. Midaz 0.15/kg
- IM: Midaz 0.3 IM/buccal/IN

Wait: 5 mins if IV, 10min if other.
Repeat BZD and commence a load:

2nd
PHENYTOIN
- 20mg/kg at 50mg/min max

Other options:
PHENYBARBITONE (kids)
- 20mg/kg (1g kids)
OR
LEVETIRACETAM (off-label)
- 60/kg (4.5g) adults
- 40mg/kg (3g) kids
OR
VALPROATE (not preg or <2yo)
- 40mg/kg

_____________

REFRACTORY:
Give an alternative 2nd line.

4th Intubate using:
- Propofol 2mg/kg induction –> 4/kg/hr
- Thiopentone same.

Ketamine, inhaled anaesthetics

Question 9

STATUS EPILEPTICUS: Tx in kids

Answer 9

Same, but:
- Phenybarbitone instead of valproate

Question 10

STATUS EPILEPTICUS: Tx in pregnancy

Answer 10

Same, but:
- MgSO4 4g over 5 mins, repeated should be considered
- No valproate

Question 11

STATUS EPILEPTICUS: How to choose a second-line loading agent when patient is chronically on an antiepileptic:

Answer 11

Generally choose an agent they’re NOT already on.

If refractory, fine to add it to the mix (tox risk outweighed by status)

Question 12

STATUS EPILEPTICUS: complications

Answer 12

Injury

Raised ICP
Cerebral oedema
Neuronal injury

Hypoxia
Acidosis (resp and lactic)
Hypoglycaemia

Hyperthermia
Rhabdo –> AKI
DIC

Question 13

Reasons for failure to return to consciousness post seizure:

Answer 13

• Ongoing non-convulsive Status
• Hypoxic/ metabolic brain injury from seizure
• Hypoglycaemia from seizure
• Underlying CNS cause for seizure (eg. encephalitis, ICH)
• Ongoing effect of sedatives/ BZDs

Question 14

What is the risk of recurrence after a first, unprovoked adult seizure?

Answer 14

50%

But only 2% go on to have epilepsy.

Question 15

Is neuroimaging in ED necessary for the work up of a first-time seizure?

Answer 15

No specific rules.

If recovered to baseline AND everything normal : IMAGING NOT INDICATED
–> 1% yield

Generally MRIB and EEG as outpatient

Question 16

Does a first time seizure need to be discharged on anticonvulsants?

Answer 16

No.

BZD as short-course of PRN not strictly indicated either.

Question 17

What is the lifetime incidence of an unprovoked seizure?

Answer 17

10%

Question 18

Discharge advice after a seizure:

Answer 18

Get sleep
Avoid triggers (recreationals, flashing)

Do not:
- Drive until cleared by Neurology
–> (as per State specific law)
—> Usually 6-12mo
- Operate heavy machinery
- Scale heights
- Swim alone
- Care for dependents alone
- Take baths
etc.

Seizure first aid
Medical alert

Question 19

FEBRILE SEIZURE: Typical age

Answer 19

6 months to 6 years

3% of healthy children will have one.

Question 20

FEBRILE SEIZURE: What constitutes a ‘simple’ febrile seizure:

Answer 20

• Generalised ton clon
• <15mins duration
• Full recovery within 1 hour
• No recurrence during same illness

Less likely if: outside 6mo-6yo, Hx afebrile seizure, neurodev, signs CNS infection etc.

Question 21

FEBRILE SEIZURE: What is the risk of recurrence? Epilepsy?

Answer 21

RECURRENT FEBRILE SEIZURE:
- Up to 50%
- Risk reduces with age (prob as less time until 6yo!)
- 1/ (1+ age)

EPILEPSY
- Generally, no increased risk (1%)
- Unless risk factors (up to 10%)
–> ‘Complex’ febrile seizure
–> Neurodevelopmental
–> FHx epilepsy

Question 22

FEBRILE SEIZURE: management

Answer 22

Simple febrile seizures that have fully resolved (where infective source apparent + benign) require NO investigation.

No role for neuroimage, EEG or outpatient follow up.

‘Complex’ febrile seizures should be DW paeds, but still usually go home for FU.