Docstoc

AFP Review

Document Sample
AFP Review Powered By Docstoc
					AFP Review


     Susana A. Alfonso, M.D.
         June 28, 2007
Evaluation of a First Seizure

 2-5% of Americans experience an
 afebrile seizure
 1-2% of all ED visits
 57% are < 25 and most of these are
 <15 YOA
Seizure Types

 Generalized involves all areas of the
 brain
 Partial (focal) involves one area
 Partial can be either simple (no LOC)
 or complex (LOC)
 Symptomatic seizure have a
 recognizable cause
 Provoked seizures is caused by a
 transient identifiable disturbance
Causes of Seizure

 New onset epilepsy is the most
 common cause of a first seizure
 One in six will have an identifiable
 cause
   Pre or perinatal brain injury (4.4%)
   CVA (3.9%)
   Head injury (3.2%)
   Brain tumor (1.7%)
   Alcohol use (0.3%)
Evaluation
 Start with ABC’s
 Determine whether a seizure actually
 occurred
 Thorough H &P
 No sign, symptom, or test clearly
 differentiates a seizure from a non
 seizure event
 Up to 20% of pts. With diagnosis of
 epilepsy have pseudo seizures
Pseudoseizures

 Eye closure is common
 Non physiologic movement especially
 pelvic thrusting
 Prolonged duration
 Poor response to anti-epileptic
 medications
DDx: Syncope

  90% have seizure like movements
 Precipitated by emotional events
 Preceded by lightheadedness,
 sweating, chest pain, palpitations,
 prolonged standing
DDx: Seizures

 Tongue biting (especially lateral)
 Aura
 Postictal confusion
 Focal neurologic signs
Diagnostic Testing: Adults

 Immediate neuroimaging:
   When serious structural brain lesion is
   suspected
   Consider for partial- onset seizures
   Adults > 40 YOA
   Patients at increased risk for intracranial
   pathology: AIDS, trauma, age > 40,
   fever, h/o anticoagulation, malignancy,
   persistent HA, and persistent AMS
Diagnostic Testing: Children

 Immediate neuroimaging:
    in a child with postictal focal neuro
   deficit that does not resolve or neuro
   status that does not return to baseline
   within several hours.
   Hx of Head trauma
   Hx of malignancy
  Seizures provoked only by fever do not
   require neuroimaging
Neuroimaging

 MRI is more sensitive and preferred
 CT is better initial choice because of
 accuracy with bleeding
Diagnostic Testing: LP and Labs

 Indicated for pts. With Hx or PE
 suggestive of infection
 Immunocompromised pts.
 Consider in children < 6months
 Labs based on clinical scenarios for
 adults
 Glucose and Sodium routinely for
 children
 Pregnancy tests
 Toxicology screening
EEG

 Recommended for all pts. With new
 onset seizures
 Emergent EEG if concerned
 regarding status epilepticus
 Immediate EEG for pts. In drug
 induced coma and who have received
 long acting paralytic agent
Future Risk

 All seizures occuring within 24 hours
 are considered a single seizure
 One half of pts. Who have a first
 unprovoked seizure and three fourths
 of pts. With multiple seizures will have
 another within eight years.
Treatment
 AAN practice guideline states that
 treatment with an antiepileptic
 medication in not indicated in children
 for the prevention of epilepsy but if
 the benefit of preventing a second
 seizure outweigh the risks. There is
 no guideline for adults
 ACEP states that pts without
 comorbities, normal neuro exam may
 be discharged without initiation of
 meds
Driving
 Most states require a 3-18 month seizure
 free period before a pt may drive a private
 vehicle
 Some states require physician reporting
  In Georgia a person with epilepsy may
 obtain a license to drive cars and small
 trucks (less than 26,000 lbs.) if he or she
 has been seizure-free for 6 months. A
 person who has only nocturnal seizures
 may be eligible for a limited license (e.g.,
 daylight driving only) even if he or she has
 been seizure-free for less than 6 months
 (www.epilepsyfoundation.org)
Universal Newborn Hearing
 Congenital hearing loss: hearing loss
 present at birth
 Incidence thought to be 2-3/1000
 Types of hearing loss
   Conductive: outer or middle ear, affects
   all frequencies
   Sensorineural: inner ear or auditory
   nerve
   Mixed
   Central: Rare, auditory pathway of the
   brain
Rationale

 Risk based screening may miss 19-
 42%
 A critical period exists for language
 skills and earlier intervention
 produces better outcomes
 Treatment improves communication
 No prospective studies of the two
 approaches…USPSTF found
 insufficient evidence to recommend
Support for Universal Screening

 AAP, CDC, Healthy People 2010
 1993 NIH Consensus Development
 Conference on Early Identification of
 Hearing Impairment in Infants and
 Children recommended
 37 states and the District of Columbia
 require universal screening
Screening Tests

 AABR: automated auditory brainstem
 response
   Tests from the ext. ear to the lower
   brainstem
 TEOAE: transient evoked otoacoustic
 emissions test
   Test the function of the peripheral
   auditory system (esp. the cochlea)
  No evidence to support one over the
   other
Pleurisy

 Pleurisy is inflammation of the parietal
 pleura
 Pleuritc pain is a symptom
   Visceral pleura has no pain receptors
   Parietal pleura at the periphery is
   innervated by intercostal nerves
   Pp central is innervated by the phrenic
   nerve
Diagnosis

 Consider life threatening causes first:
 MI, PE, pneumothorax
 5-21% presenting to ER had PE
 Consider pneumonia and pericarditis
 Pleuritic pain is classically described
 as increasing with anything that
 increases chest cavity volume
Evaluation
 H&P
 CXRAY
 ECG
 PFA
 Evaluation dependent on ruling out life
 threatening causes of pleuritic pain
 Treatment of underlying cause if pleurisy is
 the diagnosis
Findings associated with select
causes of pleuritic pain
 MI:
 Pericarditis:
 Pneumonia
 Pneumothorax
 Pulmonary Embolism
Selected Causes of Pleurisy
 Cardiac: Post-MI, post cardiac injury, post
 pericardiotomy
 Exposure: Asbestosis, medications
 (amiodarone, bleomycin, bromcriptine,
 cyclophosphamide, MTX)
 Heme/onc: Malignancy, sickle cell
 Infectious: Viral, bacterial, and parasitic
 Renal: CRI
 Rheumatologic: Lupus, RA, Sjogren’s
Treatment

 Control the symptom of pleuritic chest
 pain
 NSAIDS: Indocin used historically
 Treat the underlying condition
Hypertryiglyceridemia

 It is unclear if metabolic syndrome
 and high TG are true causal CV risk
 factors or biomarkers of future risk
 Borderline: 150-199
 High: 200-499
 Very high: 500-1999
 Severe: >2000
Diagnosis

 Fasting lipid profile
 Fasting is less important for
 measurement of LDL
Treatment: lifestyle

 Wt. loss
 regular exercise
 tobacco cessation
 avoidance of high –carb foods
 low fat and low sugar diet
Treatment
 Optimize glycemic control
 Screen for metabolic syndrome: Any
 3 of
   Abdominal circumference >40 in (men)
   and >35 in. in women
   TG >150
   HDL < 40 in men and <50 in women
   BP > 130/85
   Fasting Glucose >110
Treatment (cont)
 Search for Secondary Causes: Nephrotic
 syndrome, CRI, Hypothyroidism, meds
 Search for Acquired Causes: Obesity,
 ETOH, high carb diets, tobacco use
 Determine cardiac risk and stratify using
 Framingham risk calculators (high risk pts.
 Are those with 10 year risk >20% and
 those with CV disease and diabetes
Statins

 Can lower TG by 20-40%
 Can lower LDL by 18-55%
 Can raise HDL by 5-15%
 Can decrease all cause mortality in
 patients with known heart disease
Statins
 Used for patients with borderline or
 high TG levels who are not at LDL
 goal
 PATIENTS WITH BORDERLINE OR
 HIGH TG SHOULD HAVE AS LDL
 LEVELS AS PRIMARY GOAL
 SECONDARY GOAL IS FOR NON-
 HDL CHOLESTEROL (Total – HDL).
 This is 30 pts higher than LDL goal
WHAT????

 GR is 79 yr old female with LDL of 69,
 HDL of 50, TG of 201 and total of
 222. She is hypertensive and diabetic
 without known heart disease.
 LDL goal???
 Non HDL goal???
Patient GR
 LDL goal is 100 or 70
 Non HDL goal is 130
 Pt is at her LDL goal
 Secondary goal is non-HDL cholesterol
 Pts non-HDL cholesterol is 222-50=172
 Treat by intensifying LDL lowering therapy
 or adding niacin, fish oils, or fibrate
Treatment of Very High TG

 Initial goal to decrease the risk of
 pancreatitis (especially if TG >1000)
 TLC
 Niacin, fish oil, or fibrates
 If TG >1000, pt should be on very low
 fat diet (<15% of calories)
Fibrates

 Can lower TG by 40-60%
 Can raise HDL by 15-25%
 Can RAISE LDL by 5-30%
 No decrease in all-cause mortality
 No decrease in primary end point of
 coronary events Tricor did decrease
 the secondary endpoint of total CV
 events
Fibrates (cont)

 Fenofibrate/statin may be safer than
 gemfibrozil/statin
 Use the lowest possible combo dose
Niacin

 Can decrease TG by 30-50%
 Can raise HDL by 20-30%
 Can lower LDL by 5-25%
 Controversial regarding decreased all
 cause mortality
 Does not affect glycemic control
 Side effects limit use
Fish Oil

 Contain essential fatty acids DHA and
 EPA
 2-4gm/day can lower TG by 30-50%
 Can increase HDL by 5-10%
 Can RAISE LDL by 5-10%
 Only other lipid lowering therapy that
 lowers all cause mortality
Fish Oil (cont)

 Side effects are minimal: fishy
 aftertaste and GI
 Omacor is by prescription and claims
 to have less SE
 Available OTC but each tablet has
 around 300mg of DHA/EPA
Summary:Seizure
 New onset epilepsy is the most
 common cause of first seizure
 Image those patients at risk
 EEG is recommended for all new
 seizures
 Most patients will have another
 seizure
 Pts with seizure have driving
 limitations that vary by state
Summary: Universal Hearing
Screening
 There is insufficient evidence and
 high rate of false positive
 Required in 37 states including
 Georgia
Summary: Pleurisy

 Pleurisy is a diagnosis
 Pleuritic chest pain is a symptom
 Rule out life threatening causes of
 pleuritic pain
 Once diagnosis of pleurisy is made
 treat the underlying cause of which
 viral is most common
Summary: Hypertriglyceridemia

 LDL is primary goal
 Non-HDL is secondary goal
 Fish oils and statins are the only two
 lipid lowering therapies that have
 shown to decrease all cause mortality
 Fish oils are safe, well tolerated, and
 efficacious

				
DOCUMENT INFO