1 / 47

AFP Review

AFP Review. Susana A. Alfonso, M.D. June 28, 2007. Evaluation of a First Seizure. 2-5% of Americans experience an afebrile seizure 1-2% of all ED visits 57% are < 25 and most of these are <15 YOA. Seizure Types . Generalized involves all areas of the brain

bijan
Download Presentation

AFP Review

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. AFP Review Susana A. Alfonso, M.D. June 28, 2007

  2. Evaluation of a First Seizure • 2-5% of Americans experience an afebrile seizure • 1-2% of all ED visits • 57% are < 25 and most of these are <15 YOA

  3. Seizure Types • Generalized involves all areas of the brain • Partial (focal) involves one area • Partial can be either simple (no LOC) or complex (LOC) • Symptomatic seizure have a recognizable cause • Provoked seizures is caused by a transient identifiable disturbance

  4. Causes of Seizure • New onset epilepsy is the most common cause of a first seizure • One in six will have an identifiable cause • Pre or perinatal brain injury (4.4%) • CVA (3.9%) • Head injury (3.2%) • Brain tumor (1.7%) • Alcohol use (0.3%)

  5. Evaluation • Start with ABC’s • Determine whether a seizure actually occurred • Thorough H &P • No sign, symptom, or test clearly differentiates a seizure from a non seizure event • Up to 20% of pts. With diagnosis of epilepsy have pseudo seizures

  6. Pseudoseizures • Eye closure is common • Non physiologic movement especially pelvic thrusting • Prolonged duration • Poor response to anti-epileptic medications

  7. DDx: Syncope • 90% have seizure like movements • Precipitated by emotional events • Preceded by lightheadedness, sweating, chest pain, palpitations, prolonged standing

  8. DDx: Seizures • Tongue biting (especially lateral) • Aura • Postictal confusion • Focal neurologic signs

  9. Diagnostic Testing: Adults • Immediate neuroimaging: • When serious structural brain lesion is suspected • Consider for partial- onset seizures • Adults > 40 YOA • Patients at increased risk for intracranial pathology: AIDS, trauma, age > 40, fever, h/o anticoagulation, malignancy, persistent HA, and persistent AMS

  10. Diagnostic Testing: Children • Immediate neuroimaging: • in a child with postictal focal neuro deficit that does not resolve or neuro status that does not return to baseline within several hours. • Hx of Head trauma • Hx of malignancy Seizures provoked only by fever do not require neuroimaging

  11. Neuroimaging • MRI is more sensitive and preferred • CT is better initial choice because of accuracy with bleeding

  12. Diagnostic Testing: LP and Labs • Indicated for pts. With Hx or PE suggestive of infection • Immunocompromised pts. • Consider in children < 6months • Labs based on clinical scenarios for adults • Glucose and Sodium routinely for children • Pregnancy tests • Toxicology screening

  13. EEG • Recommended for all pts. With new onset seizures • Emergent EEG if concerned regarding status epilepticus • Immediate EEG for pts. In drug induced coma and who have received long acting paralytic agent

  14. Future Risk • All seizures occuring within 24 hours are considered a single seizure • One half of pts. Who have a first unprovoked seizure and three fourths of pts. With multiple seizures will have another within eight years.

  15. Treatment • AAN practice guideline states that treatment with an antiepileptic medication in not indicated in children for the prevention of epilepsy but if the benefit of preventing a second seizure outweigh the risks. There is no guideline for adults • ACEP states that pts without comorbities, normal neuro exam may be discharged without initiation of meds

  16. Driving • Most states require a 3-18 month seizure free period before a pt may drive a private vehicle • Some states require physician reporting • In Georgia a person with epilepsy may obtain a license to drive cars and small trucks (less than 26,000 lbs.) if he or she has been seizure-free for 6 months. A person who has only nocturnal seizures may be eligible for a limited license (e.g., daylight driving only) even if he or she has been seizure-free for less than 6 months (www.epilepsyfoundation.org)

  17. Universal Newborn Hearing • Congenital hearing loss: hearing loss present at birth • Incidence thought to be 2-3/1000 • Types of hearing loss • Conductive: outer or middle ear, affects all frequencies • Sensorineural: inner ear or auditory nerve • Mixed • Central: Rare, auditory pathway of the brain

  18. Rationale • Risk based screening may miss 19-42% • A critical period exists for language skills and earlier intervention produces better outcomes • Treatment improves communication • No prospective studies of the two approaches…USPSTF found insufficient evidence to recommend

  19. Support for Universal Screening • AAP, CDC, Healthy People 2010 • 1993 NIH Consensus Development Conference on Early Identification of Hearing Impairment in Infants and Children recommended • 37 states and the District of Columbia require universal screening

  20. Screening Tests • AABR: automated auditory brainstem response • Tests from the ext. ear to the lower brainstem • TEOAE: transient evoked otoacoustic emissions test • Test the function of the peripheral auditory system (esp. the cochlea) No evidence to support one over the other

  21. Pleurisy • Pleurisy is inflammation of the parietal pleura • Pleuritc pain is a symptom • Visceral pleura has no pain receptors • Parietal pleura at the periphery is innervated by intercostal nerves • Pp central is innervated by the phrenic nerve

  22. Diagnosis • Consider life threatening causes first: MI, PE, pneumothorax • 5-21% presenting to ER had PE • Consider pneumonia and pericarditis • Pleuritic pain is classically described as increasing with anything that increases chest cavity volume

  23. Evaluation • H & P • CXRAY • ECG • PFA • Evaluation dependent on ruling out life threatening causes of pleuritic pain • Treatment of underlying cause if pleurisy is the diagnosis

  24. Findings associated with select causes of pleuritic pain • MI: • Pericarditis: • Pneumonia • Pneumothorax • Pulmonary Embolism

  25. Selected Causes of Pleurisy • Cardiac: Post-MI, post cardiac injury, post pericardiotomy • Exposure: Asbestosis, medications (amiodarone, bleomycin, bromcriptine, cyclophosphamide, MTX) • Heme/onc: Malignancy, sickle cell • Infectious: Viral, bacterial, and parasitic • Renal: CRI • Rheumatologic: Lupus, RA, Sjogren’s

  26. Treatment • Control the symptom of pleuritic chest pain • NSAIDS: Indocin used historically • Treat the underlying condition

  27. Hypertryiglyceridemia • It is unclear if metabolic syndrome and high TG are true causal CV risk factors or biomarkers of future risk • Borderline: 150-199 • High: 200-499 • Very high: 500-1999 • Severe: >2000

  28. Diagnosis • Fasting lipid profile • Fasting is less important for measurement of LDL

  29. Treatment: lifestyle • Wt. loss • regular exercise • tobacco cessation • avoidance of high –carb foods • low fat and low sugar diet

  30. Treatment • Optimize glycemic control • Screen for metabolic syndrome: Any 3 of • Abdominal circumference >40 in (men) and >35 in. in women • TG >150 • HDL < 40 in men and <50 in women • BP > 130/85 • Fasting Glucose >110

  31. Treatment (cont) • Search for Secondary Causes: Nephrotic syndrome, CRI, Hypothyroidism, meds • Search for Acquired Causes: Obesity, ETOH, high carb diets, tobacco use • Determine cardiac risk and stratify using Framingham risk calculators (high risk pts. Are those with 10 year risk >20% and those with CV disease and diabetes

  32. Statins • Can lower TG by 20-40% • Can lower LDL by 18-55% • Can raise HDL by 5-15% • Can decrease all cause mortality in patients with known heart disease

  33. Statins • Used for patients with borderline or high TG levels who are not at LDL goal • PATIENTS WITH BORDERLINE OR HIGH TG SHOULD HAVE AS LDL LEVELS AS PRIMARY GOAL • SECONDARY GOAL IS FOR NON-HDL CHOLESTEROL (Total – HDL). This is 30 pts higher than LDL goal

  34. WHAT???? • GR is 79 yr old female with LDL of 69, HDL of 50, TG of 201 and total of 222. She is hypertensive and diabetic without known heart disease. • LDL goal??? • Non HDL goal???

  35. Patient GR • LDL goal is 100 or 70 • Non HDL goal is 130 • Pt is at her LDL goal • Secondary goal is non-HDL cholesterol • Pts non-HDL cholesterol is 222-50=172 • Treat by intensifying LDL lowering therapy or adding niacin, fish oils, or fibrate

  36. Treatment of Very High TG • Initial goal to decrease the risk of pancreatitis (especially if TG >1000) • TLC • Niacin, fish oil, or fibrates • If TG >1000, pt should be on very low fat diet (<15% of calories)

  37. Fibrates • Can lower TG by 40-60% • Can raise HDL by 15-25% • Can RAISE LDL by 5-30% • No decrease in all-cause mortality • No decrease in primary end point of coronary events Tricor did decrease the secondary endpoint of total CV events

  38. Fibrates (cont) • Fenofibrate/statin may be safer than gemfibrozil/statin • Use the lowest possible combo dose

  39. Niacin • Can decrease TG by 30-50% • Can raise HDL by 20-30% • Can lower LDL by 5-25% • Controversial regarding decreased all cause mortality • Does not affect glycemic control • Side effects limit use

  40. Fish Oil • Contain essential fatty acids DHA and EPA • 2-4gm/day can lower TG by 30-50% • Can increase HDL by 5-10% • Can RAISE LDL by 5-10% • Only other lipid lowering therapy that lowers all cause mortality

  41. Fish Oil (cont) • Side effects are minimal: fishy aftertaste and GI • Omacor is by prescription and claims to have less SE • Available OTC but each tablet has around 300mg of DHA/EPA

  42. Summary:Seizure • New onset epilepsy is the most common cause of first seizure • Image those patients at risk • EEG is recommended for all new seizures • Most patients will have another seizure • Pts with seizure have driving limitations that vary by state

  43. Summary: Universal Hearing Screening • There is insufficient evidence and high rate of false positive • Required in 37 states including Georgia

  44. Summary: Pleurisy • Pleurisy is a diagnosis • Pleuritic chest pain is a symptom • Rule out life threatening causes of pleuritic pain • Once diagnosis of pleurisy is made treat the underlying cause of which viral is most common

  45. Summary: Hypertriglyceridemia • LDL is primary goal • Non-HDL is secondary goal • Fish oils and statins are the only two lipid lowering therapies that have shown to decrease all cause mortality • Fish oils are safe, well tolerated, and efficacious

More Related