Seizures

Soma Pathak, MD PGY-2 Emergency Medicine

Overview

 Definition  Epidemiology  Clinical Features  Differential Diagnosis  Treatment  Cases

Definitions

 Seizure: episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons.  Epilepsy: clinical condition in which an individual is subject to recurrent seizures.

Epidemiology

 100,000 new cases of seizures diagnosed in the US each year  Incidence of seizures world-wide is 30.9 to 56.8 per 100,000.

 Highest rates among those less than 20 years old followed by those over 60.

 Male>Female

Generalized Seizures

 Caused by a nearly simultaneous activation of the entire cerebral cortex

Partial seizures

  Due to electrical discharges in a localized structural lesion of the brain.

Affects whatever physical or mental activity that area controls.

Partial (focal) seizures

 Simple partial no alteration of consciousness  Complex partial consciousness impaired  Partial seizures (simple or complex) with secondary generalization

Classification of Seizures

      Generalized seizures (consciousness always lost) Tonic clonic seizures (grand mal) Absence seizures (petit mal) Myclonic seizure Clonic seizures Atonic seizures

Causes: secondary seizures

     Trauma (recent or remote) Intracranial hemorrhage Eclampsia Hypertensive encephalopathy Structural abnormalities – Vascular lesion (aneurysm, AV malformation) – Mass lesion – Degenerative disease – Congenital abnormalities

Causes: secondary seizures

   Toxins and drugs Anoxic brain injury Metabolic disturbances – Hypo or hyperglycemia – Hypo or hypernatremia – Hyperosmolar states – Uremia – Hepatic failure – Hypocalcemia, hypomagnesemia (rare)

Features: generalized seizures

 Abrupt loss of consciousness and loss of postural tone  May then become rigid  With extension of the trunk and extremities  Apnea  Cyanosis  Urinary incontinence

Features: tonic clonic seizures

 As the tonic (rigid) phase subsides, clonic (symmetric rhythmic) jerking of the trunk and extremities develop  Episode lasts from 60-90 seconds  Consciousness returns gradually  Postictal confusion may persist for several hours

Features : absence seizures

       Brief, usually lasting only a few seconds. Loss of consciousness without losing postural tone.

Appear confused or withdrawn, and current activity ceases. May stare and have twitching of their eyelids.

Do not respond to voice or other stimulation Are not incontinent.

End abruptly, and there is no postictal period.

Clinical features of simple partial

    Remain localized and consciousness is not affected. Unilateral tonic or clonic movements limited to one extremity suggest a focus in the motor cortex, while tonic deviation of the head and eyes suggest a front lobe focus.

Visual symptoms often result from an occipital focus, while olfactory or gustatory hallucinations may arise from the medial temporal lobe Sensory phenomena, or aura are often the initial symptoms of attacks.

Status epilepticus

   Continuous seizure activity lasting for at least 30 min Two or more seizures without intervening return to baseline Non-convulsive status epilepticus is associated with minimal or imperceptible convulsive activity and is confirmed by EEG

History

  Careful history Important historical information: – Include rapidity of onset, – Presence of a preceding aura – Progression of motor activity (local or generalized) – Incontinence.

History

  Duration of the episode and whether there was postictal confusion Contributing factors: – Sleep deprivation – Alcohol withdrawal – Infection – Use or cessation of other drugs

History: first time seizures

 History of head trauma  Headache  Pregnancy or recent delivery  History of metabolic derangements or hypoxia  Systemic ingestion or withdrawal and alcohol use.

Physical Exam:

  Injuries resulting from the seizure – such as fractures, sprains, strains, posterior shoulder dislocation, tongue lacerations, and aspiration. Localized neurological deficits – Todd’s paralysis

Differential diagnosis

 Syncope  Hyperventilation syndrome  Complex migraine  Movement disorders  Narcolepsy  Pseudo-seizures

Treatment: Airway:

 Oxygen  Pulse oximetry  Endotracheal intubation – for prolonged seizure  If RSI is performed, a short acting paralytic agent should be used so that ongoing seizure activity can be observed

Treatment:

 Breathing: – Suction – Airway adjuncts  Circulation: IV access  IV glucose if confirmed hypoglycemia

First Line Medication: Benzodiazepines

 Midazolam (Versed) IV/IM  Diazepam (Valium) IV/ET/IO/PR  Lorazepam (Ativan) IV/IM

Second line medications:

 Phenytoin/fosphenytoin  Phenobarbital

Third line medication:

 General anesthesia with continuous EEG –Infusions of midazolam, propofol, or pentobarbital –Inhaled isoflurane

First Line Anticonvulsants

DRUG ADULT DOSE PEDS DOSE OTHER INFO Diazepam Lorazepam Midazolam .2mg/kg up to 20mg at 2mg/min .1mg/kg IV max 10mg at 2mg/min **Intranasal use promising .1mg/kg IV up to 10mg at 1mg/min or .2mg/kg IM **Intranasal use promising .2-.5mg/kg IV/IO or .5-1.0mg/kg PR up to 20mg CNS/CV/Resp depression Onset 1min Lasts 20-30min (longer PR) .05-.1mg/kg IV .15mg/kg IV .2mg/kg IM CNS/CV/Resp depression Onset 2min Lasts >12hrs Less depression Onset 1min Short duration

Case 1:

 14 month old healthy female with cough and nasal congestion x 2 days, with tactile temperature and 30 second episode of “shaking”?

– PE?

– Dx?

– Treatment?

Seizures in children

 Aged 0-9 years, prevalance is 4.4 cases per 1000,  Aged10-19 years old 6.6 cases per 1000  Simple febrile convulsions occur in 3 4% of children

Febrile seizures

 Antiepileptic drug therapy are only used in pts with: – Underlying neuro deficit (ie CP) – Complex febrile seizure – Repeated seizure in the same febrile illness – Onset under 6 mos of age or more than 3 febrile seizures in 6 mos.

Febrile seizures:

 Aged 3 month to 5 years  Identify and treat cause  Acetaminophen, ibuprofen and tepid water baths.  Family history increases risk.

Case 2

 19 year old healthy female breast feeding a newborn has a tonic-clonic seizure – PE? – Dx?

– treatment?

Eclampsia

 Pregnant women beyond 20 weeks’ gestation or up to 8 weeks postpartum.

 Seizures  Hypertension  Edema  Proteinuria

Eclampsia:

 Treatment: administration of magnesium sulfate 4 g IV  Followed by 1-2 mg/ hr, in addition to antiepileptic meds

Case 3:

 50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on tegretol. – PE?

– Dx?

– Treatment?

Epilepsy

 Breakthrough seizures vs. noncompliance with medications  Precipitating factors – Infection – Drug use  Treat or stabilize any injuries secondary to convulsions

Epilepsy: management

     ABC’s Monitor VS and check blood glucose Treat any injuries Transport to appropriate hospital IV and ALS monitor

A/P: no longer seizing:

    Recovery position IV Blood glucose Medication history

A/P is seizing still

   Airway assessment (npa, suction, ETT prn) Protect patient from self injury Pulse-ox, monitor, IV access, blood glucose – Hypoglycemia is the most common metabolic but can also be a result of prolonged seizure – Medications

Case 4:

 34 yo male with hx of alcoholism found s/p seizure.  Pt is confused and combative.  Vomiting.

Delerium Tremens (DT’s)

 Advanced stage of alcohol withdrawal  Altered mental status  Generalized seizures  6-48 hours after the last drink.  Status epilepticus

Delerium Tremens (DT’s)

    Tremors Irritability Insomnia Nausea/vomiting     Hallucinations (auditory, visual, or olfactory) Confusion Delusions Severe agitation

Treatment:

     Airway – Suction at hand – high risk for aspiration – oxygen IV access Immediate glucose testing or D50 administration thiamine administration (100 mg IV) benzodiazepines in actively seizing pts.

Treatment of DT’s:

  Do not use neuroleptics Administer adequate sedation – To blunt agitation to and prevent the exacerbation of hyperthermia, acidosis, and rhabdomyolysis.

Delirium tremens:

   Potentially fatal form of ethanol withdrawal. Symptoms may begin a few hours after the cessation of ethanol, but may not peak until 48-72 hours.

Early recognition and therapy are necessary to prevent significant morbidity and death.

Case 5:

 22 yo female with 2 episodes of “shaking” in last 6 hours with active seizing for 15 minutes. – PE?

– Dx?

– Treatment?

Status Epilepticus

    Continuous seizure activity lasting for at least 30 min, or two or more seizures without intervening return to baseline Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min) Impending SE if >3 tonic-clonic seizures within 24hrs Generalized or Partial

Status Epilepticus

 The longer the seizure continues – The more difficult it is to stop – The more likely permanent CNS injury will occur

Treatment

 Protect airway airway (NPA, OPA, ETT). If RSI is required, use short acting paralytics.

 Obtain IV access  FS blood glucose  Cardiac monitoring

   First line – Diazepam (Valium) IV/ET/IO/PR – Lorazepam (Ativan) IV/IM – Midazolam (Versed) IV/IM Second line – Phenytoin/fosphenytoin – Phenobarbital (may cause respiratory and circulatory depression) Lastly induction of general anesthesia w. cont. EEG – Infusions of midazolam, propofol, or pentobarbital – Inhaled isoflurane

Questions??