Adult Seizure Management for the Family Practitioner Huey Lin, R3 Swedish Family Medicine December 2001 Case - Charlie B or C Brown 27 year old male who I saw in saw in clinic in February 2001 for back pain who was recently admitted for change in mental status. 5-10 seconds of blurry vision -> resolved. Then 30 minutes later, asked to help a co- worker. From this point on, no memory of what happened. Case continued From co-worker: Chas came to help me and I noted his shirt was wet. He sat down next to me. Then the gum he was chewing fell out of his mouth, and he was drooling. I couldn’t snap him out of it - even after shaking him. He then got back up and weaved around the room a little before sitting down next to another co- worker. Case continued Another co-worker: Charles then sat next to me, and seemed dazed. When I asked him where he was, he kept on saying, “yeah, yeah, yeah” for some time. He then seemed to recognize me, and that’s when we called the paramedics. It was very, very odd. I think he’s “into” something… <wink, wink> Case continued From the ER MD: Mr. Brown came in about 30 minutes after his event. He seemed lucid, coherent. He was complaining of a headache, and the first thing he remembers is talking to Mr. Van Pelt. He had no visible trauma and had not lost continence. We drew the usual labs and did the complimentary head CT - but only one per visit. Case continued Yeah, I felt pretty good by the time I got to the ER. I knew what was happening. Something like this has happened to me before, but I’ll tell you more about that later. I was in a car crash in spring 2000 and my noggin got a goose egg, but that’s about it. As to my family, my great grandfather had seizures - but he was born really premature. And yeah, I admit...I smoke a little weed about 1-2 times a week. Epidemiology of Epilepsy Estimated 2-4 million people in the US -- about 1 of 50 children and 1 of 100 adults -- are affected Some debate if prevalence higher in children or the elderly Less than 50% have an identifiable cause There is a 9% cumulative lifetime incidence rate of seizures; but only a 3% cumulative lifetime incidence of epilepsy Causes of Epileptic Seizures Fewer than half of patients have an identifiable cause. Congenital brain malformations, inborn errors of metabolism, high fever, head trauma, brain tumors, CVA, intracranial infection, cerebral degeneration, withdrawal states, and iatrogenic drug causes. Common Causes of Provoked Seizures Massive sleep deprivation Excessive stimulant use Withdrawal from sedative drugs or alcohol Substance abuse (cocaine, methamphetamine) High fever Hypoglycemia Electrolyte imbalance Hypoxia Differential Diagnosis of Seizures Syncope Panic attacks Paroxysmal sleep behavior Pseudoseizures Breath-holding spells Basic seizures types Loss of consciousness? Cortical area affected NO PART OF CORTEX Simple partial Simple partial Complex partial - usually temporal lobe YES Complex partial ENTIRE CORTEX Generalized tonic-clonic Generalized tonic-clonic Absence Absence Simple Partial Seizure Usually lasts 5-10 seconds; most less than a minute Symptoms dependent on cortical area involved No loss of consciousness No postictal state Difficult to differentiate between psychiatric disorders (key is paroxysmal nature and duration of seizure) EEG - normal or focal spikes Complex Partial Seizure Most common type of seizures in adults Variable duration, but typically less than 3 minutes Appears awake, but not responsive - often stare or have automatisms If restrained, may become hostile or aggressive Postictal period - somnolence, confusion, and headache up for up to several hours No memory of what took place during seizure EEG - focal activity spreading to involve one or both hemispheres Generalized Tonic-Clonic Seizure Usually lasts 1-2 minutes Abrupt loss of consciousness, often preceded by scream All muscles become stiff (tonic) followed by twitching/jerking movements (clonic) Expect cyanosis, mouth injuries, or other bodily injuries Can be preceded by any partial seizure Postictal period - usually deep sleep with hyperventilation then gradual wakening with complaint of headache EEG - series of generalized, high-amplitude spikes Absence Seizure Usually lasts between 5-10 seconds; but frequently in clusters Considered a seizure disorder of childhood Absence before age 5 associated with mental retardation and tendency for future seizures Sudden staring with impaired consciousness with eye blinking and lip smacking for longer seizures EEG - characteristic generalized, 3 per second, spike and wave Epileptic Syndromes and Other Seizure Types There are other seizure types such as clonic, myoclonic, tonic, and atonic. There are epileptic syndromes characterized by patterns of clinical features, age of onset, family history, and associated neurologic signs and symptoms. BUT, almost all of the other seizures types and all of the syndromes have onset in childhood and so will not be reviewed today. Clinical Evaluation of Seizures HISTORY is the most important part of the clinical evaluation. Pointed questions are often needed. Obtain as accurate of a description from patient and witness(es). Clinical Evaluation of Seizures Before the seizure… • Was there an aura? • Was there an identifiable trigger? • If there is a history of seizure, what are known precipitants or triggers. Clinical Evaluation of Seizures During the seizure… Was there signs of impaired consciousness? • What was the patient actually doing? • Was there loss of urine or stool? • How long did the episode last? • If h/o seizures, was this a typical/atypical episode? Clinical Evaluation of Seizures After the seizure… For the observer, was the patient postictal? If no observer, did patient know where he/she was, what had happened immediately after episode? • If postictal, how long was it? • Did the patient have any complaints when s/he became more awake? Clinical Evaluation of Seizures Other history to obtain besides event history: Medical history: febrile seizures, head injury, CVA, malignancy, infectious diseases Family history: febrile seizures, epilepsy in close relative, h/o neurological disorders Social history: travel, occupation, substance abuse Back to C. Brown... Aura? Maybe…had blurry Duration? About 3 minutes vision 30 minutes prior to Postictal? Difficult to say… episode headache, little groggy, but Trigger? Not identifiable claims knew his location Impaired consciousness? immediately afterwards “Yeah, yeah, yeah” Medical history: h/o minor Good description from head trauma, unusual witnesses about event episode earlier in month Loss of continence? Family history: yes, but Negative dirty underwear distant relative sign. Social history: no travel, works in medical setting, likes joints Back to C. Brown… With this history, did this gentleman have a seizure? If so, what type of seizure? Seizure Management Acute Seizure Management Airway Breathing Circulation Acute Seizure Management – Status Epilepticus Vast majority of adult seizures will complete in 2 minutes; few will go into status epilepticus. Status epilepticus is defined as: one generalized tonic-clonic seizure lasting more than 5 minutes or two generalized tonic-clonic seizures occurring in 1 hour Acute Seizure Management – Status Epilepticus Benzodiazepines • Lorazepam – 0.1 mg/kg IV at 1-2 mg/min up to 10 mg. One protocol lists 4 mg as good initial dose. • Diazepam - 0.2 mg/kg IV at 2 mg/min up to 20 mg. Can also be given ET or PR. • Midazolam - 2.5-15 mg IV or 0.2 mg/kg IM. Very short acting. BE PREPARED TO INTUBATE! Acute Seizure Management – Status Epilepticus Fosphenytoin Fosphenytoin - 15-20 phenytoin equivalent/kg at 100-150 mg phenytoin equivalent/min; may be given IM. • 20-30 minute onset so must also use smaller doses of benzodiazepine • Give too rapidly and may cause hypotension or arrhythmias. Acute Seizure Management – Status Epilepticus Barbituates • May also be used, but majority of experience with this medication is the ER setting with pediatric patients on in the ICU setting for refractory seizures. • Still may be useful in adults who are seizing because of phenobarbital withdrawal. • Be prepared to intubate and support blood pressure. • Propofol and phenobarbital are acceptable options for treating refractory seizures in ICU setting. • Get help from a neurologist if you are in the ICU. Back to Clinical Evaluation… • When the environment is more calm, do a complete history and physical exam Spend time on a thorough neurological exam Correct any suspected underlying causes Back to Clinical Evaluation… Laboratory Data • Chem 7, Ca, Mg, CBC with differential, toxicology screens • Drug levels if patient is on an anticonvulsant. EEG • More than 50% of patients with epilepsy have normal EEG. • Consider sleep-deprived EEG if resting EEG is normal and suspicion is still high. Back to Clinical Evaluation… MRI • Head CT can be used if suspect mass lesion, hemorrhage, or large stroke. Also used if MRI is contraindicated. Consider… • Lumbar pucture • Holter monitoring and/or other cardiac evaluation • Neurology consult Back to C. Brown… • Physical exam was normal. • Chem 7, Ca, Mg, CBC with differential, toxicology screens were done. Positive for cannibanoids. • Resting EEG was normal. • Telemetry monitoring normal. • Echocardiogram and carotid Doppler duplex normal. • Follow up with me as outpatient. Back to C. Brown… • Neurology referral made. • Made it clear to patient that he cannot drive, swim, take a bath, or operate heavy equipment. • Several days later, received call that had two more similar episodes witnessed by mother. • Phone interviewed mother…virtually identical behavior, BUT she notes a more postictal state – confused for several minutes after event. Back to C. Brown… • Scheduled outpatient MRI and outpatient sleep deprived EEG. • Curbsided neurologist to see if medication needed to be started. Seizure Management - Medication When to start medication? Definitely start if: • there is a structural lesion, such as tumor, AV malformation, infection • EEG with a definite epileptic pattern • history of brain injury or stroke, CNS infection, significant head trauma • Todd’s postictal paresis • Status epilepticus on presentation Otherwise, get neurology consult. Seizure Management - Medication • Most common medications used are phenytoin, valproate, and carbamazepine. • Each neurologist seems to have his/her drug of preference. • For absence seizure, ethosuximide is clearly the drug of choice. Seizure Management - Medication • Although not proven in controlled studies, it is still believed that monotherapy is advantageous. • Can use Swedish Online Pharmacology or Epocrates to establish dosing, side effects, and monitoring guidelines. • As always, be aware of drug-drug interactions, metabolism in the elderly, and non-compliance due to side effects. Seizure Management - Medication • Monitoring AED levels most helpful when patient is doing well and when s/he is symptomatic. • Generally, at the outset need to monitor regularly – consider weekly. Once benchmark blood level obtained, can then monitor annually as long as no breakthrough seizures. Seizure Management - Medication • Stopping medication should be weighed against newer studies showing 20-30% recurrence. General rule of thumb has been seizure free for 2 years. • If stopping medication, must be a slow taper over months. Seizure Management - Medication NEW MEDICATION • Felbamate • Gabapentin • Lamotrigine • Topiramate • Tiagabine • Levetiracetam • Oxcarbazepine • Zonisamide Seizure Management – Nonpharmacologic • Vagus Nerve Stimulation • Epilepsy Surgery Back to C. Brown… • Spoke with neurologist’s partner who agreed with outpatient workup and starting patient on ½ maintenance dose of valproate (usual maintenance dose is 15 mg/kg/d). Back to C. Brown… • Charlie sees the neurologist, has had another two brief < 5 second episodes in the interim, this time just with drooling. Confused? • However, Charlie tells the neurologist that he NEVER had a postictal state. • Neurologist thinks he needs a cardiac workup and recommends a colleague. Back to C. Brown… • Curbsided cardiologist who is very confused… • In the meantime, get MRI results back. There is a linear area of increased signal in periventricular white matter of the left temporal lobe suggestive of old ischemia or gliosis. Back to C. Brown Mother reports to neurologist her son’s previous episodes and confirms that there was a postictal period. Neurologist calls me back telling me he will see Charlie again and this time probably start him on medication. Cheers all the way around for the team effort!