Sheezoos !

1. Sheezoos! As quoted to me by a nice lady describing the affliction suffered by her husband

2. Anticonvulsants • Epilepsy • The second most common neurologic illness in North America • 0.5%-1% of the US population • They all live in Indianapolis • 70% have no identifiable cause (primary or idiopathic) • 30% have underlying cause (secondary epilepsy)

3. So what causes seizures? Infectious diseases Trauma Metabolic disorders Vascular diseases Pediatric disorders Neoplastic disease Plus…. Medications High doses of local anesthetics Eclampsia Drug abuse Withdrawal syndromes from ETOH or sedative-hypnotic drugs

4. Seizures of unknown etiology • Lower tolerance to environmental triggers: • Sleep deprivation • Flickering lights • Fluid and electrolyte imbalances • In neonates, infants, children • Congenital abnormalities of CNS • Perinatal brain injury • Metabolic imbalances • In later childhood: CNS infections, neurological degenerative disorders • Adult etiology • Cerebral trauma or neoplasm • CVA

5. Types of Seizures • Partial seizures • Simple partial • Complex partial • Generalized seizures • Absence • atonic • Tonic-clonic (grand mal) • Special seizures • Febrile • Myoclonic • Status epilepticus

6. Partial Seizures • Simple partial • Limited portion of the brain • Abnormal focus or foci • Patients experience • Felling that they are not really present wherever they are • Hallucinations with all senses • Extreme emotions • Twitching of arms, legs, or face • Complex partial • Altered LOC • Involve sensory, motor, and autonomic symptoms • Aura commonly precedes • No memory of seizure

7. Generalized Seizures • Travel throughout the brain • Include the following: • Absence Seizures • Common in children • Subtle symptoms: • Staring • transient LOC • eyelid fluttering • myoclonic jerks • Atonic seizures • Last only a few seconds • characterized by stumbling or falling

8. Generalized Seizures (cont) • Tonic Clonic-most common • Usually preceded by aura • Tonic phase • Intense muscle contractions • Hoarse cry at onset • Loss of bowel or bladder control • Shallow breathing • Clonic phase • Alternating contraction and relaxation of muscles • Postictal state • Drowsiness, disorientation, deep sleep • Patients will differ in this part

9. Special Seizures • These guys usually involve the pediatric population • Febrile • Last 1-2 minutes with tonic-clonic activity • 3-5 year-old age group in conjunction with a rapid rise in temp • It’s not how high the temperature is, but how fast it rises • Myoclonic • Involve large, jerking body movements with major muscle groups contracting quickly • Occurs in infants, but often mistaken for a normal Moro (startle) reflex • Status seizures

10. Status Seizures • A seizure lasting longer than 3 minutes or two or more consecutive seizures without regaining consciousness • These are the ones we medicate in the field • But first: • Check blood glucose (it’s the easiest thing to fix) • O2, IV, monitor (often difficult in a flopping patient) • Midazolam (Versed) • > 50 kg, 5 mg IV, IM, IN • < 50 kg, 2.5 mg • Peds: 0.1 mg/kg (up to 2.5 mg)

11. Anticonvulsant Therapy Primary goal of drug therapy is to control or prevent the recurrence of the seizure disorder No ideal seizure med You need to have an idea of what med works on what type of seizure to know what type of seizure history your patient has

12. Major Anticonvulsant Classifications Hydantoins & phenytoin-like drugs Barbiturates Succinamides Benzodiazepines Miscellaneous

13. Hydantoins Reduce the maximal activity of brainstem centers responsible for tonic-clonicseizures by desensitizing Na+ channels Developed from a search for a drug that was less sedating than the barbs Treatment for all types of epilepsy except absence seizure More effective on grand mal than petit mal Used after head trauma and brain surgery • Examples: • phentyoin (Dilantin) • fosphenytoin (Cerebyx)

14. Phenytoin-like Drugs Works like the hydantoins in desensitizing Na+ channels • Examples • carbamazepine (Tegritol) • Tonic-clonic and partial • lamotrigine (Lamictal) • valproic acid (Depakene, Depakote) • Absence seizures

15. The GABA Potentiators Barbiturates Benzodiazepines Other miscellaneous GABA agents Suppresses the firing ability of neurons

16. Barbiturates • Relatively inexpensive; efficacious, low incidence of side effects • Used for generalized tonic-clonic and partial seizures • phenobarbital • Most commonly prescribed barbiturate • Remember this is a CNS depressant, and it takes several weeks to achieve maximum effects with minimal sedation • Optimal blood concentration is determined by seizure control and an absence of toxic effects • That’s why docs will draw levels if they are on phenobarb and have a seizure (as long as they are compliant with the meds)

17. Benzodiazepines • This is certainly a repeat category, isn’t it? • diazepam, clonazepam, lorazepam • A fat girl with a good personality • Lower incidence of acute toxicity and OD • More favorable side and adverse effect profiles • Lower abuse potential • Fewer potentially serious drug interactions • diazepam is our prototype, but midazolam is protocol • Although it is not recommended for seizures due to the short half-life

18. valproic acid (Depakene), valproate (Depacon), divalproex sodium (Depakote) • Directly or indirectly increases or enhances GABA • Something about reuptake of GABA by glial cells and axonal terminals • Dissociates to valproic acid in the stomach • Absence seizures and adjunctive in multiple seizure types • levetiracetam (Keppra) • Fairly new; used as adjunct therapy in all seizures except absence • MOA is a mystery, it works to suppress areas others don’t

19. Succinamides We don’t see these much, so I won’t waste a slide on them. But thanks for coming. (Okay, they suppress seizures by delaying calcium influx into neurons.) I don’t care about these ones.

20. Most effective drugs with the least toxicity

21. And our focus is, as always • ABCs • Protect the patient • Don’t put your fingers in the patient’s mouth (duh) • Obtain a thorough history • r/o low sugar, hypoxia, and trauma • Seizure patients with a known history often refuse to go to the hospital • Follow SOR guidelines, and advocate in the best interest of the patient • Many patients are not compliant with medication, mainly because they cannot drink alcohol with the meds

22. Medication Noncompliance The number 1 reason seizure patients have seizures You can’t make them compliant, but you can warn them of the dangers of repeat seizure activity

23. Things to know from this lecture Causes of seizures Types of seizures Classes of seizure meds and the corresponding medication names (both) What types of meds work on what types of seizures