Download Generalized Seizures

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Appear confused or withdrawn, and current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
 Diazepam
(Versed) IV/IM
(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
.2mg/kg up to
20mg at
2mg/min
.2-.5mg/kg IV/IO CNS/CV/Resp
or .5-1.0mg/kg
depression
PR up to 20mg
Onset 1min
Lasts 20-30min
(longer PR)
Lorazepam
Midazolam
.1mg/kg IV max
10mg at
2mg/min
.05-.1mg/kg IV
**Intranasal use
promising
.1mg/kg IV up to .15mg/kg IV
10mg at
.2mg/kg IM
1mg/min or
.2mg/kg IM
**Intranasal use
promising
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 34% 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
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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
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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)

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Tremors
Irritability
Insomnia
Nausea/vomiting
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Hallucinations
(auditory, visual, or
olfactory)
Confusion
Delusions
Severe agitation
Treatment:

Airway
– Suction at hand
– high risk for aspiration
– oxygen

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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:


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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??