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SEIZURES Powered By Docstoc
AHD Nov 4, 2009, Kristine Bertsch R2
   Classification
   Approach
     ABCs,   Hx, O/E, Invest, Rx
   CFPC Priority Topics & Key Features:
     Manage    acute seizure
     History to distinguish seizure, to determine cause, to
      guide investigations, and to monitor epileptics on Rx
     Physical exam to check for focal neuro findings
   Seizure: transient episode of abnormal excessive
    neuronal activity
     5-10% lifetime incidence
     Primary/idiopathic vs secondary/symptomatic
   Epilepsy is recurrent unprovoked seizures
       0.5-1% people
   Epileptic syndromes are groups of epileptics patients
    with similar seizures and response to Tx
   Aura is the sensations the pt has before consciousness is
    lost, and for which memory is retained (simple partial
Classification (ILAE)

          *Partial seizures can become generalized, or spread to
          other body parts (Jacksonian march), and they may have
          Post-ictal Todd’s Palsy or aphasia
   Called by triage RN to admitting, because an 18
    year old female is seizing in the waiting room
     Alllimbs convulsing rhythmically
     Appears cyanotic, drooling

     RNs have put on O2 and are protecting her head

     Accompanied by mother, who appears very scared

     Mother reports she had a similar seizure at home
      before coming in (private vehicle!)
CPFC Objectives
   In a pt having a seizure:
     Ensureproper airway control
     Use drugs to stop it, even before etiology known

     R/O metabolic causes in a timely fashion
Acute Seizure Management
   General principles: cABCs
     Protect C-spine (gentle but firm restraint of head &
      neck), turn on side to prevent aspiration
     O2, suction PRN, consider oral airway, monitor SaO2
       Usually   not possible to ventilate
   Early vitals (esp Temp) and bedside glucose
   When seizure ends, establish IV PRN, draw labs,
    begin Hx, do P/E, determine etiology

Acute Seizure Management
   After 5 minutes, STATUS EPILEPTICUS!
   Used to be >30 minutes
   Consult neurology and anaesthesia
   Ensure O2 well applied, frequent suction, monitor sat,
    apply cardiac monitor, establish IV, check bedside G
    and vitals, draw labs, think about intubating, draw up
   Labs= CBC, lytes, Ca, Mg, PO4, Cr, G, bHCG, tox screen (urine
    and blood), AED levels
   Thiamine 100mg IV and G 25-50g IV if hypoG suspected
   Rectal thermometer, Foley, NG tube
   STAT IV Abx if bacterial meningitis suspected
Acute Seizure Management
   Options for acute seizure Tx if >5 minutes:
     Lorazepam 2-4 mg IV over 2 minutes, rpt x1 PRN
     Diazepam 10-20 mg IV or PR
       Resp depression and hypotension
       Consider following with phenytoin

   Phenytoin 18-20mg/kg IV at 25 mg/min
       Hypotension,    dysrhythmia, infusion-site reaction
   Fosphenytoin 15-20mg PE/kg IV at 100-150/min
       Can    infuse faster, but $$$
   Midaz drip, propofol drip, phenobarb, EEG monitor
   CCFP Objectives:
     In a pt presenting with a seizure, take a Hx to
      appropriately guide investigation
     In a pt with an ill-defined episode, take a Hx to distinguish
      seizure vs other events
     In a pt with previously known seizure d/o, who presents with
      a seizure or change in seizures,
           Take Hx to include factors that affects seizures: seizure meds
            (compliance, recent changes), other meds, EtOH, lifestyle, other
           Include other c/o seizure in the DDx (not all caused by epilepsy)
   To include in history:
     Seizure   vs other event
     Description of event: onset (+/- aura), ictal, post-ictal

     Clinical context (PMHx, Surg Hx, meds, all, Soc Hx, FHx)

     FIFE, illness experience
Seizure vs Other
   DDx seizure, syncope, pseudoseizures, migraine,
    narcolepsy/cataplexy, mvmt disorder (ie hemiballismus)
   Key is to get full Hx of event pre-, during, and post-
     Witness account whenever possible
     Premonitory symptoms/aura, abrupt vs gradual onset, motor
      activity (local vs generalized, symmetrical vs not), loss of
      bowel/bladder control, tongue-biting, injuries, duration of
      attack, post-ictal confusion/lethargy, recall of event
   Classify Seizure
   Clinical context
       If previous seizures:
         Baseline frequency? Triggers? Meds, compliance (HUGE!), last
          dose, missed doses, recent med changes? Other meds?
         Sleep deprivation? Infxn? EtOH? Using other drugs? Lifestyle
         Is current seizure same, or new type? (Consider new c/o seizure!)
       If first seizure:
         FHx? Head injury? Pregnant? Hx of lyte/metabolic abnormalities?
          Cancer? Coagulopathy? Meds? EtOH/drugs?
         Any Hx to suggest prior unrecognized seizures? (Blank stares,
          unexplained injuries, enuresis)
   FIFE
DDx Seizure Causes/Triggers
   Primary/idiopathic
   Secondary/symptomatic (DIMS)
     Drugs:  EtOH, illicit drugs, toxins, antidepressants,
     Infectious: intracranial infection

     Metabolic: hyper/hypo G, Na, hypoxia, hypo Ca/Mg,
      hyperthermia, uremia, hepatic failure, eclampsia
     Structural: IC bleed, CVA, trauma, mass (vascular, tumor,
      congenital, degenerative)
Physical Examination
   CCFP Objective: In a pt presenting with a seizure,
    examine closely for focal neuro findings

   cABC done
   Secondary survey: Look for injuries
       Head/neck, tongue, aspiration, post shoulder disloc
   Directed neurological exam
     LOC, mentation (beware progressive deterioration!)
     Focal neuro deficits
     Signs of increased ICP
   Labs
       CBC, lytes, Ca, Mg, Cr, urea, G, bHCG, tox screen, urine for Hgb
        (if +, check serum CPK for ?rhabdo)
       +/- ABG (lactic acidosis), prolactin (not reliable)
       Anticonvulsant level (may be only lab needed in pt with well-
        documented seizure disorder who has a single, unprovoked
   Imaging
       Noncontrast CT for structural lesions if:
           First seizure, new seizure type, focal deficits, persistent ΔLOC, head
            trauma, coagulopathy, HIV, immunosupp, EtOH, meningismus
       Follow-up contrast CT/MRI PRN
   EEG usually not possible in ER, but do ASAP
   Whether to treat after first seizure is controversial
     Generally  treat if irreversible precipitant
     If unprovoked, 31-71% 1 yr recurrence rate

     Consult neuro for advice

     Options include valproic acid, phenytoin,
      carbamazepine, others
       Valproicacid SEs= ataxia, sedation, tremor
       Phenytoin SEs=ataxia, diplopia, dizziness, incoord, confusion
       Carbamazepine SEs= ataxia, diplopia, dizziness, vertigo
   ACEP Guidelines for Neuro Consult in ER
     First seizure/new type, focal neuro, persistent ΔLOC,
        new IC lesion, poorly controlled seizures, pregnant
   Admit if:
        persistent ΔLOC, CNS infection, new IC lesion,
        underlying correctable med problem, eclampsia, head
        trauma, status epilepticus
Special Considerations
   If EtOH, consider withdrawl and admit for Tx
     Usual withdrawl seizures are 6-48h after last
      drink/cutting down, generalized, and may be multiple.
      Tx= BDZs, detox
     DDx head trauma, IC bleed, toxic-metabolic
       Head   CT if suspect
   If pregnant and >20 weeks, think eclampsia!
     But don’t forget stroke as an etiology… urgent head CT
     Urgent Obs consult, Mg Sulf, lorazepam/diazepam,
   Usually anti-epileptics are continued for at least 1 year
   Avoid precipitants
       Good sleep hygiene, limit EtOH intake, stress reduction
   Safety
       Avoid driving at least 3 months and until EEG/imaging
         6 months on meds if Dx epilepsy, or 12 months after Sx
         Commercial drivers must be seizure-free for 12 months
         Use discretion, consult CMA Driver’s Guide or Alberta Driver’s
          Fitness Branch
       Caution bathing, swimming, working at heights
Long-Term Management
   In the ongoing care of a pt with a stable seizure
     Regularly    enquire about compliance (with meds and
      lifestyle), side effects of meds, and the impact of the
      d/o and its Tx on lifestyle (ie driving, having seizures in
      front of friends/family)
     Monitor for med SEs (osteoporosis, hematologic)

     Modify mgmt of other conditions considering
      anticonvulsants (pregnancy, prescribing Abx)
Long-Term Management
   Med compliance is a common issue
       Teens, those lacking $$ for meds
       Some meds have short half-life and even one missed dose can
        precipitate seizure
   Side effects can be troubling or dangerous!
       Neuro SEs most common- ataxia, diplopia, dizziness, sedation, vertigo,
        mental clouding
       BM suppression & hepatotoxicity (carbamazepine and valproic acid),
        Stevens-Jonhson Syndrome (lamotrigine)
   Consider drug interactions
       OCP, Abx, MANY other meds. (Pt and MD should develop good
        relationship with pharmacist)
   Ask about effect on lifestyle, work, mood
   Consider pregnancy/lactation
   Tintinelli 2009, Seizures and Status Epilepticus in
   Harrison’s Principles of Internal Medicine 17th Ed,
    Chapter 363, Seizures and Epilepsy
   Status Epilepticus Adult Treatment Protocol,
    Columbia University Comprehensive Epilepsy
    Centre, 2006