Seizures

1. Seizures Soma Pathak, MD PGY-2 Emergency Medicine

2. Overview • Definition • Epidemiology • Clinical Features • Differential Diagnosis • Treatment • Cases

3. Definitions • Seizure: episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons. • Epilepsy: clinical condition in which an individual is subject to recurrent seizures.

4. Epidemiology • 100,000 new cases of seizures diagnosed in the US each year • Incidence of seizures world-wide is 30.9 to 56.8 per 100,000. • Highest rates among those less than 20 years old followed by those over 60. • Male>Female

5. Generalized Seizures • Caused by a nearly simultaneous activation of the entire cerebral cortex

6. Partial seizures • Due to electrical discharges in a localized structural lesion of the brain. • Affects whatever physical or mental activity that area controls.

7. Partial (focal) seizures • Simple partial no alteration of consciousness • Complex partial consciousness impaired • Partial seizures (simple or complex) with secondary generalization

8. Classification of Seizures • Generalized seizures (consciousness always lost) • Tonic clonic seizures (grand mal) • Absence seizures (petit mal) • Myclonic seizure • Clonic seizures • Atonic seizures

9. Causes: secondary seizures • Trauma (recent or remote) • Intracranial hemorrhage • Eclampsia • Hypertensive encephalopathy • Structural abnormalities • Vascular lesion (aneurysm, AV malformation) • Mass lesion • Degenerative disease • Congenital abnormalities

10. Causes: secondary seizures • Toxins and drugs • Anoxic brain injury • Metabolic disturbances • Hypo or hyperglycemia • Hypo or hypernatremia • Hyperosmolar states • Uremia • Hepatic failure • Hypocalcemia, hypomagnesemia (rare)

11. Features: generalized seizures • Abrupt loss of consciousness and loss of postural tone • May then become rigid • With extension of the trunk and extremities • Apnea • Cyanosis • Urinary incontinence

12. Features: tonic clonic seizures • As the tonic (rigid) phase subsides, clonic (symmetric rhythmic) jerking of the trunk and extremities develop • Episode lasts from 60-90 seconds • Consciousness returns gradually • Postictal confusion may persist for several hours

13. Features : absence seizures • Brief, usually lasting only a few seconds. • Loss of consciousness without losing postural tone. • Appear confused or withdrawn, and current activity ceases. • May stare and have twitching of their eyelids. • Do not respond to voice or other stimulation • Are not incontinent. • End abruptly, and there is no postictal period.

14. Clinical features of simple partial • Remain localized and consciousness is not affected. • Unilateral tonic or clonic movements limited to one extremity suggest a focus in the motor cortex, while tonic deviation of the head and eyes suggest a front lobe focus. • Visual symptoms often result from an occipital focus, while olfactory or gustatory hallucinations may arise from the medial temporal lobe • Sensory phenomena, or aura are often the initial symptoms of attacks.

15. Status epilepticus • Continuous seizure activity lasting for at least 30 min • Two or more seizures without intervening return to baseline • Non-convulsive status epilepticus is associated with minimal or imperceptible convulsive activity and is confirmed by EEG

16. History • Careful history • Important historical information: • Include rapidity of onset, • Presence of a preceding aura • Progression of motor activity (local or generalized) • Incontinence.

17. History • Duration of the episode and whether there was postictal confusion • Contributing factors: • Sleep deprivation • Alcohol withdrawal • Infection • Use or cessation of other drugs

18. History: first time seizures • History of head trauma • Headache • Pregnancy or recent delivery • History of metabolic derangements or hypoxia • Systemic ingestion or withdrawal and alcohol use.

19. Physical Exam: • Injuries resulting from the seizure • such as fractures, sprains, strains, posterior shoulder dislocation, tongue lacerations, and aspiration. • Localized neurological deficits • Todd’s paralysis

20. Differential diagnosis • Syncope • Hyperventilation syndrome • Complex migraine • Movement disorders • Narcolepsy • Pseudo-seizures

21. Treatment: Airway: • Oxygen • Pulse oximetry • Endotracheal intubation • for prolonged seizure • If RSI is performed, a short acting paralytic agent should be used so that ongoing seizure activity can be observed

22. Treatment: • Breathing: • Suction • Airway adjuncts • Circulation: IV access • IV glucose if confirmed hypoglycemia

23. First Line Medication: Benzodiazepines • Midazolam (Versed) IV/IM • Diazepam (Valium) IV/ET/IO/PR • Lorazepam (Ativan) IV/IM

24. Second line medications: • Phenytoin/fosphenytoin • Phenobarbital

25. Third line medication: • General anesthesia with continuous EEG • Infusions of midazolam, propofol, or pentobarbital • Inhaled isoflurane

26. First Line Anticonvulsants

27. Case 1: • 14 month old healthy female with cough and nasal congestion x 2 days, with tactile temperature and 30 second episode of “shaking”? • PE? • Dx? • Treatment?

28. Seizures in children • Aged 0-9 years, prevalance is 4.4 cases per 1000, • Aged10-19 years old 6.6 cases per 1000 • Simple febrile convulsions occur in 3-4% of children

29. Febrile seizures • Antiepileptic drug therapy are only used in pts with: • Underlying neuro deficit (ie CP) • Complex febrile seizure • Repeated seizure in the same febrile illness • Onset under 6 mos of age or more than 3 febrile seizures in 6 mos.

30. Febrile seizures: • Aged 3 month to 5 years • Identify and treat cause • Acetaminophen, ibuprofen and tepid water baths. • Family history increases risk.

31. Case 2 • 19 year old healthy female breast feeding a newborn has a tonic-clonic seizure • PE? • Dx? • treatment?

32. Eclampsia • Pregnant women beyond 20 weeks’ gestation or up to 8 weeks postpartum. • Seizures • Hypertension • Edema • Proteinuria

33. Eclampsia: • Treatment: administration of magnesium sulfate 4 g IV • Followed by 1-2 mg/ hr, in addition to antiepileptic meds

34. Case 3: • 50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on tegretol. • PE? • Dx? • Treatment?

35. Epilepsy • Breakthrough seizures vs. noncompliance with medications • Precipitating factors • Infection • Drug use • Treat or stabilize any injuries secondary to convulsions

36. Epilepsy: management • ABC’s • Monitor VS and check blood glucose • Treat any injuries • Transport to appropriate hospital • IV and ALS monitor

37. A/P: no longer seizing: • Recovery position • IV • Blood glucose • Medication history

38. A/P is seizing still • Airway assessment (npa, suction, ETT prn) • Protect patient from self injury • Pulse-ox, monitor, IV access, blood glucose • Hypoglycemia is the most common metabolic but can also be a result of prolonged seizure • Medications

39. Case 4: • 34 yo male with hx of alcoholism found s/p seizure. • Pt is confused and combative. • Vomiting.

40. Delerium Tremens (DT’s) • Advanced stage of alcohol withdrawal • Altered mental status • Generalized seizures • 6-48 hours after the last drink. • Status epilepticus

41. Tremors Irritability Insomnia Nausea/vomiting Hallucinations (auditory, visual, or olfactory) Confusion Delusions Severe agitation Delerium Tremens (DT’s)

42. Treatment: • Airway • Suction at hand • high risk for aspiration • oxygen • IV access • Immediate glucose testing or D50 administration • thiamine administration (100 mg IV) • benzodiazepines in actively seizing pts.

43. Treatment of DT’s: • Do not use neuroleptics • Administer adequate sedation • To blunt agitation to and prevent the exacerbation of hyperthermia, acidosis, and rhabdomyolysis.

44. Delirium tremens: • Potentially fatal form of ethanol withdrawal. • Symptoms may begin a few hours after the cessation of ethanol, but may not peak until 48-72 hours. • Early recognition and therapy are necessary to prevent significant morbidity and death.

45. Case 5: • 22 yo female with 2 episodes of “shaking” in last 6 hours with active seizing for 15 minutes. • PE? • Dx? • Treatment?

46. Status Epilepticus • Continuous seizure activity lasting for at least 30 min, or two or more seizures without intervening return to baseline • Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min) • Impending SE if >3 tonic-clonic seizures within 24hrs • Generalized or Partial

47. Status Epilepticus • The longer the seizure continues • The more difficult it is to stop • The more likely permanent CNS injury will occur

48. Treatment • Protect airway airway (NPA, OPA, ETT). If RSI is required, use short acting paralytics. • Obtain IV access • FS blood glucose • Cardiac monitoring

49. First line • Diazepam (Valium) IV/ET/IO/PR • Lorazepam (Ativan) IV/IM • Midazolam (Versed) IV/IM • Second line • Phenytoin/fosphenytoin • Phenobarbital (may cause respiratory and circulatory depression) • Lastly induction of general anesthesia w. cont. EEG • Infusions of midazolam, propofol, or pentobarbital • Inhaled isoflurane

50. Questions??