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Seizures

Seizures. A Engelbrecht. Content. Introduction Principles of management Case studies 1 – 7 Conclusions. Principles of management. First step is to confirm that a pulse is present. Principles of management. Protect and maintaining the airway

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Seizures

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  1. Seizures A Engelbrecht

  2. Content • Introduction • Principles of management • Case studies 1 – 7 • Conclusions

  3. Principles of management • First step is to confirm that a pulse is present

  4. Principles of management • Protect and maintaining the airway • Patient turned on her side to protect against aspiration • Trauma case: entire board tipped on side

  5. Principles of management • Protect patient from self-injury • Establish IV access if possible • Consider: • Suction • NP airway • Pulse oximeter • Oxygen • Prepare for endotracheal intubation

  6. Principles of management • ABC DEFG • Hypoglycemia!

  7. Principles of management • Benzodiazepines • Lorazepam (Ativan), diazepam (Valium), midazolam (Dormicum) • If IV access cannot be achieved diazepam may be given • rectally • intraosseous • NOT endotracheally

  8. Benzodiazepines • Rectal diazepam stops seizures in 70% • Midazolam can be given IM • Research: buccal midazolam works in children

  9. Buccal or nasal administration of midasolam

  10. Lorazepam • IV access: lorazepam is agent of choice • Terminates higher percentage of seizures on first dose than diasepam • Longer half-life: less recurrence of seizures • Specifically recommended for alcohol withdrawal seizures, due to longer duration of action

  11. Dosages of Benzo’s

  12. Persistent seizures despite benzo administration • Check Airway • If airway is compromised • Or sats below 90% • Intubate • If max dose benzo been reached (3X) • Give second drug

  13. Second drug: • Phenytoin: I.V. Loading dose – • Manufacturer :10-15 mg/kg • Common use: 15-20 mg/kg • Maximum rate: 50 mg/minute • I.V. effects: Hypotension, tachycardia, cardiac arrhythmia, cardiovascular collapse (especially with rapid I.V. use), venous irritation and pain, thrombophlebitis • Seizures in overdose! • Fosphenytoin less side effects, but more expensive

  14. Purple glove syndrome (Phenytoin)

  15. Second drug: Valproate • IV valproate is safe • Rapid infusions ≤45 mg/kg over 5-10 minutes (1.5-6 mg/kg/minute) were generally well tolerated in clinical trials • Onset of anticonvulsant effects are slower than phenytoin • Adverse hematologic effects: thrombocytopenia (1% to 24%; dose related)

  16. Persistent seizures • Rapid sequence intubation • Neuromuscular blocking agent is administered to reduce metabolic burden and hyperthermia • General anesthetic doses of midazolam or propofol (TIVA) • Anesthetic dosing midazolam is 0.2 to 0.3 mg/kg bolus, then 0.05 to 2.0 mg/kg/hr, and for propofol it is 2 to 4 mg/kg, then 1 to 15 mg/kg/hr • Inotropic support • Mechanical ventilation and critical care

  17. Case number 1: • A 45 year old male patient was admitted to the orthopaedic ward for a fracture of the left ankle after a minor fall • GCS is 15/15 – no sign of a head injury • 8 hours after admission the patient develops generalized tonic clonic seizures • He has no history of epilepsy

  18. Case number 1 • How would you manage this case? • A family member says that he is depressed and has lots of problems at home and at work. How would this influence your differential diagnosis? • Which deficiencies do you expect and how would you correct it? • What effect does ethanol have on GABA?

  19. Case number 2:

  20. Case number 2: • What are the characteristics of typical febrile seizures? • Age 6m – 5j; tonic-clonic; <15minutes • % of patients with typical febrile seizures with a positive LP? • <1% • % of patients with atypical febrile seizures with a positive LP? • > 2.5%

  21. Case number 2: • The child visited Mosambique with his parents and returned 10 days ago • The malaria smear and antigen is negative but you find neck stiffness on clinical examination • What are the most common CNS infections that may cause seizures? • Meningitis, encephalitis, cerebral abscess, cerebral parasitosis and CNS manifestations of HIV

  22. Neurocysticercosis

  23. Case number 3 • A known epileptic present to your emergency department • She is a 14 year old female • She had intermittent seizures for the last 30 minutes • She is on two anticonvulsant medications (unknown) • She is brought in by friends • During your initial management you insert an iv line and administer a dose of lorasepam

  24. Case number 3 • She continues to fit even after subsequent doses of lorasepam to the maximum reccomended dose. What is your next step? • Are you allowed to give a second line therapy (fenitoin or valproate*) prior to obtaining plasma levels? • Consolidated treatment program is lorasepam and half loading dose of 2nd line agent When level is back tailor dose of longer acting)

  25. Case number 3 • What is status epilepticus? 1hour? 30minutes? 5minutes? • Body can withstand convultions for 1 hour max • After 30 minutes Ca++ fluxes into neurons and cause cell damage • Convultions are unlikely to terminate spontaneously if the persevered beyond 5 minutes • Newest defenition is 5 minutes based on above

  26. Case number 3 • How long do you expect the post-ictal period to last? • Usually no longer than 20 minutes • The patient appears to have a L hemi-paresis after his last convultion. What is your differential diagnosis? • Consider Todd’s Paralysis (exclusion)

  27. Case number 4 • A 16 year old female presents to your emergency department • She had two episodes of seizures on her way to hospital in the back of an ambulance • She recently failed her school exams and will have to repeat the school year • She was found next to empty packets of medication prescribed to her mother • Her bloodpressure is 60/40 and her pulserate is 140 per minute

  28. ECG of case number 4

  29. Case number 4 • What is your ECG diagnosis and immediate management? • Which drugs are associated with seizures? • Cyclic antidepressants, antihistamines, • cocaine, amphetamines, alcohol withdrawal, phenytoin, carbamazepine, plant toxins, insecticides, rodenticides, antimicrobials, cardiovascular drugs ect.

  30. Case number 5: • A 22 year old female present to the emergency department with tonic-clonic seizures • She does not respond to first line therapy • Her blood pressure is 220/160 • What is your next step?

  31. Case number 5 • Her B-HCG is positive • Abdominal examination reveals a palpable abdominal mass extending above the umbilicus • Which anticonvulsant should be administered first? • A series of systematic reviews reported magnesium sulfate was safer and more effective than phenytoin and diazepam

  32. Case number 6: • A known patient with a pancreatic malignancy present to your emergency department • He suddenly develop an episode of seizures • It is terminated by 2mg of iv lorasepam • What could have caused his seizure? • Which electrolyte abnormalities are most commonly associated with seizures?

  33. Case number 7: • An elderly resident of a Frail care home present to your emergency department after an episode of seizures • He is known with Altzeimers disease and has a severely diminished short term memory • He has a bruise to the side of the head and a low grade fever of 37.5 degrees Celsius • He appears confused and has a RR of 25 per minute

  34. Case number 7 • What is your differential diagnosis?

  35. Conclusions: • Seizure is a sign of an underlying condition and not a diagnosis • Try to determine the root cause • ABC • DEFG • Benzo – second line – RSI - TIVA

  36. Questions ?

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