seizure

Question 1

acute symptomatic seizure / provoked seizure

Answer 1

a seizure that occurs at the time or soon after the onset of an acute systemic or CNS condition

Question 2

things that might provoke seizures

Answer 2

within 1 week of stroke, TBI, anoxic encephalopathy, or intracranial surgery
subdural hematoma
acute CNS infection
exacerbation of MS or other autoimmune disease
metabolic disturbance
drug/alcohol intoxication or withdrawal

Question 3

reflex seizure

Answer 3

a seizure constantly evoked by a particular stimulus (trigger) that lowers seizure threshold eg. flashing lights

Question 4

unprovoked seizure

Answer 4

a seizure that occurs in the absence of an identifiable cause or beyond the specifies interval after an acute CNS condition

Question 5

What does ‘ictal’ mean?

Answer 5

occurring during a seizure

Question 6

What does ‘interictal’ refer to?

Answer 6

occurring between the seizures

Question 7

Define ‘postictal’.

Answer 7

occurring after a seizure

Question 8

What is epilepsy?

Answer 8

A chronic neurologic disorder characterized by a predisposition to seizures.

Question 9

What defines epilepsy according to the criteria?

Answer 9

Two or more unprovoked or reflex seizures separated by more than 24 hours or one unprovoked or reflex seizure in an individual at high risk.

Question 10

What is an epilepsy syndrome?

Answer 10

A group of epileptic disorders characterized by a set of features typically occurring together.

Question 11

What is reflex epilepsy?

Answer 11

Epilepsy in which seizures are consistently provoked by a certain trigger.

Question 12

Name a few subtypes of reflex epilepsy.

Answer 12

• Photosensitive epilepsy
• Musicogenic epilepsy
• Catamenial epilepsy (in which seizures coincide with certain phases of the menstrual cycle)

Question 13

What is drug-resistant epilepsy?

Answer 13

Epilepsy in which at least two antiepileptic drugs have failed to prevent seizures.
30% of epilepsy is drug resistant

Question 14

What defines resolved epilepsy?

Answer 14

An age-dependent epilepsy syndrome that has not recurred in individuals past the applicable age.

Question 15

What are the criteria for resolved epilepsy?

Answer 15

No recurring seizures for 10 years in individuals who have not taken antiepileptic drugs for at least the last 5 years.

Question 16

focal seizures

Answer 16

may manifest with intact or impaired awareness
start with an aura
may involve automatisms, clonic involuntary movements of contralateral limbs or facial muscles
tonic contraction of contralateral limbs
includes mom motor symptoms

Question 17

Todd paralysis

Answer 17

Todd paralysis: postictal weakness or paralysis of the involved limb or facial muscles (can last for minutes or up to 36 hours)
following focal seizure

Question 18

generalised onset seizures

Answer 18

Involve one/both hemispheres
Start with loss of consciousness.
Patients do not recall the seizure.

Question 19

grand mal seizure

Answer 19

tonic clonic
seizure
prodromal seizure up to hours before onset
loss of consciousness sudden and without warning
motor symptoms
bladder and bowel incontinence
tongue bite lacerations
usually lasts 1-3 minutes

Question 20

motor symptoms of grand mal seizure

Answer 20

1. tonic phase:
   - generalised muscle contractions, rotated eyes, apnea, lateral tongue biting, pooled oral secretions, cyanosis, and characteristic loud moan (ictal cry)
   - increased sympathetic tone: dilated, unresponsive pupils, increased HR, increased BP
2. clonic phase
   - rhythmic muscle twitching

Question 21

post ictal symptoms of grand mal seizure

Answer 21

unresponsiveness which may last a few seconds or up to an hour
confusion
amnesia of the event
aphasia
fatigue
muscular flaccidity and muscle pain
headache
hypersalivation with or without airway obstruction

Question 22

clonic seizure

Answer 22

loss of consciousness with bilateral rhythmic jerking and amnesia of the event

Question 23

tonic seizure

Answer 23

often occurs when patient is drowsy, asleep or waking
loss of consciousness
muscle stiffening
autonomic symptoms
amnesia of the event and drowsiness after

Question 24

absence seizure

Answer 24

blank stare, unresponsiveness
common feature of childhood epilepsy syndromes
can occur up to 100 times per day and last <10 seconds

Question 25

difference between focal to bilateral tonic clonic seizure and generalised tonic clonic seizure

Answer 25

important to distinguish as they are managed differently if focal to bilateral seizure progresses rapidly, initial focal symptoms may go unnoticed leading to potential misdiagnosis of generalised onset seizures and innappropriate therapy

Question 26

work up for first seizure

Answer 26

clinically evaluate type of seizure identify metabolic abnormalities consider neuroimaging to evaluate for structural cause obtain an EEG evaluate for underlying cause

Question 27

labs to consider for seizure work up

Answer 27

FBC glucose electrolytes prolactin (increased for 15 minutes following some seizures) tox screen ESR rapid plasma reagin to rule out syphilis creatinine kinase renal and liver function antiepileptic drug level cultures thyroid, adrenal, pituitary function tests

Question 28

if a seizure lasts >5 minutes it is called

Answer 28

status elipticus less likely to resolve spontaneously early initiation of medical treatment is associated with a higher probability of seizure termination and a better prognosis

Question 29

for seizures less than 5 minutes

Answer 29

monitor and prepare for benzodiazepine administration

Question 30

treatment of status elipticus

Answer 30

urgently administer parenteral benzodiazepine IV lorazepam or diazepam if no response to benzodiazepine, start parenteral antiepileptic drug

Question 31

preferred antiepileptic drugs

Answer 31

IV fosphenytoin IV valproic acid IV leveteracitam

Question 32

if status epileptics is not interrupted it can lead to

Answer 32

Status epilepticus is a life‑threatening condition. If not interrupted, it can lead to cerebral edema, hyperthermia, rhabdomyolysis, and cardiovascular failure. If the time from seizure onset is unknown, begin management for status epilepticus.

Question 33

initial stabilisation for acute seizures

Answer 33

call for help and remove hazards A-E assessment airway manoeuvres, oxygen, recovery position to prevent aspiration check POC glucose and vital signs O2 monitoring and sats monitoring with continuous ECG IV access and blood samples

Question 34

metabolic acidosis following seizure

Answer 34

A severe but self-limited metabolic acidosis due to marked and transient hyperlactatemia commonly occurs immediately after a seizure and usually does not require specific intervention. [

Question 35

which airway should be used in a seizing patient

Answer 35

When indicated in an actively seizing patient, a nasopharyngeal airway is preferred over an oropharyngeal airway to avoid damaging intraoral structures in the setting of muscle spasms.

Question 36

rapidly reversible causes of seizures

Answer 36

hypoglycaemia, hyponatraemia, hypocalcaemia

Question 37

phase based acute seizure management

Answer 37

Question 38

which drugs are generally used for pregnant women needing anti-epileptics

Answer 38

lamotrigine, leveteracitam

Question 39

what other important advice should be given to women with epilepsy wanting to get pregnant

Answer 39

Supplementation with 5mg folic acid per day is recommended for all women with epilepsy, starting 3 months prior to conception and throughout the first trimester. Women on antiepileptic drugs are recommended to take a higher dose of folic acid (5mg instead of 0.5mg) because these medications can interfere with folate metabolism, increasing the risk of neural tube defects in the developing fetus.

Question 40

what are the appropriate drug concentration for first line therapy?

Answer 40

midazolam OR diazepam 10mg IV or 0.2mg/kg for a child up to 10mg give over at least 2 minutes

Question 41

what is the appropriate drug dosage if IV access cannot be obtained

Answer 41

midazolam 10mg IM OR midazolam 5 to 10mg buccally or intranasal

Question 42

second line antiepileptic drugs if benzodiazepines fail

Answer 42

levetiracetam IV or sodium valproate IV. Phenytoin sodium is equally efficacious but not preferred due to adverse effect profile and requirement for slow infusion rate

Question 43

how would you give antiepiletics if IV access is not available

Answer 43

intraosseously

Question 44

which anti epileptics should you give for children

Answer 44

levetiracetam phenytoin sodium valproate (avoid in children under 3 due to risk of hepatotoxicity) phenobarbital (not preferred due to risk of respiratory depression when given after a benzodiazepine, use in ICU setting if needed)

Question 45

what to do if the seizure continues despite a benzodiazepine and an antiepileptic

Answer 45

transfer to ICU with continuous EEG when to escalate to an anaesthetic drug with artificial ventilation depends on a variety of factors, seek expert advice Ongoing seizures with airway or respiratory compromise should prompt early escalation, to minimise the risk of injury to the central nervous system. As a general guide, an infusion of a general anaesthetic (eg thiopentone, propofol) should be started in patients who are still having seizures after 15 minutes

Question 46

complications of seizures

Answer 46

aspiration trauma if seizures are prolonged: CNS injury non cariogenic pulmonary oedema rhabdomyolysis, acidosis and kidney failure hyperthermia