Seizure Management for the Family Practitioner epilepsy

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					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
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-
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
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
                 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

   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
   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
   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
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
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
• 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 Management
Acute Seizure Management

                  Airway

                  Breathing

                  Circulation
Acute Seizure Management – Status

 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
  two generalized tonic-clonic seizures occurring in 1
Acute Seizure Management – Status


•   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.

Acute Seizure Management – Status

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


•   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
                 • Drug levels if patient is on an

                 • More than 50% of patients
                   with epilepsy have normal
                 • Consider sleep-deprived EEG
                   if resting EEG is normal and
                   suspicion is still high.
Back to Clinical Evaluation…
                 • Head CT can be used if
                   suspect mass lesion,
                   hemorrhage, or large stroke.
                   Also used if MRI is

                 • 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
Back to C. Brown…
               •    Neurology referral made.
               •    Made it clear to patient that
                    he cannot drive, swim, take a
                    bath, or operate heavy
               •    Several days later, received
                    call that had two more similar
                    episodes witnessed by
               •    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
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
                •   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
                •   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 –

                 •   Vagus Nerve
                 •   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
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!

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