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Seizures

Seizures. 1-2% of the pop. has recurren sz Primary epilespy-onset 10-20 yo Secondary Intracranial pathology Extravascular pathology. Partial Seizures. Simple focal seizures- motor, sensory, autonomic. No LOC

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Seizures

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  1. Seizures

  2. 1-2% of the pop. has recurren sz • Primary epilespy-onset 10-20 yo • Secondary • Intracranial pathology • Extravascular pathology

  3. Partial Seizures • Simple focal seizures- motor, sensory, autonomic. No LOC • Complex partial sz (temporal lobe or psychomotor)- associated with LOC, automatisms, and postictal • Secondary generalized partial seizures (tonic clonic/grand mal)-onset followed by a generalized sz, coma and slow return to consciousness. May see tongue biting or incontinence.

  4. Generalized Seizures • Nonconvulsive- Absence (petit mal) brief alteration of Level of consciousness. Motor tone may increase or decrease. • Convulsive- tonic clonic, grand mal

  5. Todd’s paralysis a focal paralysis following a seizure that last 1-2 hours to 1-2 days.

  6. Generalized Sz Occurs without warning Tonic clonic movements Prolonged postictal period Syncope Prodrome or darkening vision Nausea May have brief tonic clonic movement No postictal period Distinguish seizure from syncope

  7. Workup • First time seizure- glucose and sodium. May need electrolytes, CBC, U/A, LP, alcohol/tox screen, anticonvulsant levels (if taking) and chest x ray. • Indications for Neuroimaging • Status epilepticus • Recent head inj. • Prolonged postictal state • Severe headache • New focal deficit • Suspected lesion • New seizure in pts at risk for HIV or malignancy

  8. Status Epilepticus • Last >30 minutes or repetitive sz without return to baseline. • Mortality rate as high as 30% • Treatment • Intubation as needed • Oxygen • EEG monitoring if paralytic is used

  9. IV • Thiamine and Glucose (hypoglycemia/alcoholim/malnutrition) • Mag sulfate 20ml 10% solution if eclamptic alcoholic or malnourished • Diazepam or lorazepam IV q 5 min • Phenytoin (18-20mg/kg)/Fosphenytoin at 25-50 mg/min; if no response then phenobarbital 8-20mg/kg at 60min.

  10. Treatment in Children • Airway management • IV of glucose 2-4ml/kg of 25% sol.prn • Pyridoxine 50-100mg slowly (neonates) • Calcium gluconate 4ml/kg IV (neonates) • Lorazepam 0.05-0.1mg/kg at 2mg/min (can give rectally) • Phenytoin 15-20mg/kg IV rate of <40mg/min • Phenobarbital 15-20mg/kg IV rate of 25-30mg/min

  11. Additional med facts • Phenytoin and diazepam are erratically absorbed (do not give IM) • Lorazepam and fosphenytoin are rapidly absorbed IM. • Do not give Phenytoin rapidly d/t hypotension, dysrhythmias and heart block. • Full loading doses of phenobarbital can cause respiratory depression. • Phenytoin toxicity • Lateral gaze nystagmus at 20mcg/ml • Ataxia and nystagmus at >30mcg/ml

  12. Preparing for the Written Board Exam in Emergency Medicine by Carol Rivers, MD

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