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Download Clinical Case Scenario Mr. Cesar
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Seizures for the Internist Stephanie K. Zia, MD Assistant Professor Clinical Internal Medicine & Pediatrics Med/Peds Hospitalist March 2015 ▪ ▪ ▪ ▪ ▪ Identify important elements of a patient’s history pertinent to a patient with seizures Develop a differential diagnosis for a patient with seizures Risk-stratify the most likely etiology for a seizure in a patient based on history and clinical presentation Distinguish and provide initial management for lifethreatening seizures using A-B-C-D-E-F-G Discuss appropriate management and work-up for a patient with seizures ▪ ▪ ▪ Describe status epilepticus and its clinical importance Discuss a therapeutic approach to seizures in pregnancy Describe common side effects associated with antiepileptic therapy You get called by the nurse to come assess Mr. Cesar for twitching and nonresponsiveness. When you arrive to his bedside, you note that he has twitching of his arms and legs, and will not respond to your voice. Hint: go back to the basics…. Seizure interventions • Reason for admission • Past medical history • Medications • h/o seizure disorder • h/o trauma After ABC’s, take care of the 1, 2, 3’s… ▪ Step 1: H&P to rule out other conditions ▪ Syncope ▪ TIA ▪ Step 2: Once seizure confirmed… ▪ Determine acute symptomatic seizure vs unprovoked seizure ▪ Treatment should always be directly at underlying cause A good history, physical, and neurologic exam are key to diagnosis and may allow physicians to make the diagnosis without additional diagnostic studies! DDx seizures Epilepsy ▪ Affects 2.2 million Americans and 65 million people worldwide ▪ 4th most common neurologic disorder in US ▪ Increasing incidence in elderly ▪ Higher incidence in African American and socially disadvantaged populations ▪ Definition ▪ Presence of two or more repeated unprovoked seizures Types of Seizures ▪ Generalized Tonic-Clonic ▪ aka Grand Mal Seizure ▪ Absence ▪ aka Petite Mal Seizure ▪ No aura/postictal state ▪ Induced by hyperventilating ▪ EEG with characteristic 3-per-second spike & wave pattern Types of Seizures ▪ Simple Partial ▪ Focal seizures with preserved consciousness ▪ Small volume of cortex involved ▪ Complex Partial ▪ Focal seizures that impaired consciousness ▪ Typically originate from temporal or frontal lobes ▪ Can secondarily generalize Review Symptoms of a Seizure (Ictal) ▪ Aura: ▪ subjective sensations ▪ Behavior: ▪ Mood or behavioral changes before the seizure ▪ Preictal Symptoms: ▪ described by patient or witnessed ▪ Vocal: ▪ Cry or gasp, slurring of words, garbled speech Appendix 5 Neurology 2007;69:1996-2007 Symptoms of a Seizure (Ictal) ▪ Motor: ▪ ▪ ▪ ▪ ▪ ▪ Head or eye turning Eye deviation Posturing Jerking (rhythmic) Stiffening Automatisms (purposeless& repetitive) ▪ Generalized or focal movements Appendix 5 ▪ Respiration: ▪ Change in breathing pattern ▪ Cessation of breathing ▪ Cyanosis ▪ Autonomic: ▪ Pupillary dilation ▪ Drooling ▪ Change in respiratory or heart rate ▪ Incontinence ▪ Pallor ▪ Vomiting Neurology 2007;69:1996-2007 Symptoms Following a Seizure (Post-Ictal) Post-ictal states usually last up to ~30 min – 1 hour ▪ Amnesia for events ▪ Confusion ▪ Lethargy ▪ Sleepiness ▪ Headaches and muscle aches ▪ Transient focal weakness ▪ Nausea or vomiting ▪ Biting of tongue Appendix 5 Neurology 2007;69:1996-2007 Work-Up Depends on suspected etiology Partial Seizures commonly get more complete work-up as an inpatient AAN Practice Parameter Recommendations Approach to First Unprovoked Seizure in Adults EEG ▪ should be considered part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure ▪ Has value in determining risk for seizure recurrence Neurology 2007;69:1996-2007 AAN Practice Parameter Recommendations Approach to First Unprovoked Seizure in Adults Neuroimaging ▪ Brain imaging with CT or MRI should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure Neurology 2007;69:1996-2007 Seizures and Imaging ▪ Important to rule out underlying symptomatic cause (stroke, malignancy, ICH, mass) ▪ MRI with gadolinium superior to non-contrast CT (except for SAH or hemorrhagic stroke) ▪ Role of functional imaging tests (PET, photon emission CT, functional MRI) ▪ Use when planning for epilepsy surgery Review 1 Review 2 AAN Practice Parameter Recommendations Approach to First Unprovoked Seizure in Adults Laboratory tests ▪ Laboratory tests, such as blood counts, blood glucose, and electrolyte panels (particularly sodium), may be helpful as determined by the specific clinical circumstances based on the history, physical, and neurologic examination Neurology 2007;69:1996-2007 AAN Practice Parameter Recommendations Approach to First Unprovoked Seizure in Adults Laboratory tests (cont) ▪ Lumbar Puncture ▪ may be helpful in specific clinical circumstances in the adult with an apparent unprovoked first seizure ▪ Toxicology screening ▪ May be helpful in specific clinical circumstances Insufficient data to support or refute recommending LP/toxicology screens for routine evaluation of adults presenting with an apparent first unprovoked seizure Neurology 2007;69:1996-2007 Treatment of Seizures ▪ Usually not started unless: ▪ patient has 2nd unprovoked seizure ▪ Increased risk factors ▪ EEG/structural abnormalities identified during initial work-up Treatment Counsel About Triggers! Medications Illness Stress Menstruation Photic Stimulation Sleep deprivation Review Treatment ▪ Selection of anti-epileptic drug (AED) based on seizure type ▪ Generalized Seizures: ▪ Phenytoin, Phenobarbital, Valproic Acid, Levetericetam ▪ Partial Seizures: ▪ Carbamazepine, Valproic Acid, Levetericetam, Lamotrigine, Oxcarbazepime, Topiramate, Zonisamide, etc Review Case 3 Leukopenia, thrompocytopenia Stevens Johnson syndrome Sleep disturbance Gum hyperplasia, Stevens Johnson Poor concentration Metabolic acidosis hepatotoxicity Review Common Side Effects of AEDs Special Populations & Areas of Consideration Status Epilepticus (SE) ▪ Considered a neurologic emergency ▪ Definition has evolved ▪ Earliest definition—by duration—continuous seizure > 1 hr ▪ 30 minutes new “time period” given evidence of pathologic changes and worsening prognosis associated with seizures persisting 30 minutes ▪ >30* vs >5** minutes of continuous seizure activity or 2 or more sequential seizures without full recovery of consciousness between seizures ▪ “nutshell” definition—acute, prolonged epileptic crisis ▪ Different classifications ▪ EEG helpful for identifying subtypes *MKSAP **Epilepsy Foundation Seizures and Pregnancy ▪ Risk for birth defects is doubled (2-3%4-6%) from baseline with use of one AED ▪ 8% risk if on > polytherapy ▪ Treatment recommendation: ▪ Maintain on monotherapy if possible at lowest dose possible ▪ Minimum folate intake 1-2 mg daily ▪ Goal of treatment: Control seizures ▪ Increased risk of placental abruption, early labor, premature delivery with uncontrolled seizures Slide You get called by the nurse to come assess Mr. Cesar for twitching and nonresponsiveness. When you arrive to his bedside, you note that he has twitching of his arms and legs, and will not respond to your voice. Mr. Cesar is a 55 year old male with a history of diabetes mellitus who presents with a foot ulcer and was admitted for IV antibiotics and work-up to rule out osteomyelitis. He was scheduled to have a pre-operative nuclear study this afternoon and was made NPO after breakfast, while awaiting his procedure. ABC’s You get called by the nurse to come assess Mr. Cesar for twitching and non-responsiveness. When you arrive to his bedside, you note that he has twitching of his arms and legs, and will not respond to your voice. Mr. Cesar is a 55 year old male who was admitted for grave disability and placed on a 5150 hold by psychiatry. The nurses on 2E report that he had been exhibiting aggressive behavior earlier in the day and was involved in an altercation with another patient. Details are unclear, as the incident was not witnessed. ddx On physical exam, he is found to have abrasions on his face and some soft tissue swelling in his temporal region. Pupils are irregularly reactive to light (2 mm OD, 5 mm OS). You get called by the nurse to come assess Mr. Cesar for twitching and non-responsiveness. When you arrive to his bedside, you note that he has twitching of his arms and legs, and will not respond to your voice. skip Mr. Cesar is a 55 year old male with a longstanding history of primary generalized seizure disorder. His last seizure was 3 months prior to admission. He takes his Valproic Acid twice a day and cannot remember the last time he missed a dose. He was admitted last night for nausea, vomiting, and abdominal pain and was found to have pancreatitis. He continues to have frequent emesis and is currently NPO. Treatment • NPO except meds • Give AED in IV form • Seizure precautions • Decision must be individualized! • Seizure free x 2 years • No epileptiform spikes on repeat EEG • Normal MRI • Must be at least 3-12 months seizure free before driving privileges can be reinstated (varies by state) ▪ A-B-C-D-E-F-G ▪ Crash cart ▪ Activate chain of command as warranted ▪ Basic PE ▪ Labs ▪ Interventions depending on clinical presentation ▪ Medications ▪ Studies ▪ Consults ▪ Long-term considerations and counseling ▪ EEG for first unprovoked seizure ▪ Neuroimaging ▪ CT vs MRI ▪ Labs ▪ CBC, BMPglucose & Na ▪ additional studies as warranted based on H&P, Neuro exam ▪ +/- LP ▪ +/- Utox Time for Review… What are the signs and symptoms of the 4 main types of seizures? Types of Seizures Describe three categories in the differential diagnosis of seizures ddx What imaging study is preferred after a new onset seizure? Imaging Describe the sequence of how to acutely manage a patient with a seizure ABC’s What approaches can be taken with intractable epilepsy? Imaging Name the situations in which CT is preferred over MRI in the work-up of seizures What is status epilepticus? >30* vs >5** minutes of continuous seizure activity or 2 or more sequential seizures without full recovery of consciousness between seizures What factors contribute to the risk of recurrence after an initial seizure? Risk Factors What metabolic derangements are most commonly associated with seizures? What are the key elements of PE you should perform in a patient with seizures? What AEDs can be used in the management of generalized seizures? Treatment What triggers must you counsel your patients about? Triggers Match the associated side effect with AED ▪ Phenytoin (Dilantin) ▪ Valproic Acid (Depakote) ▪ Phenobarbital ▪ Carbamazepine (Tegretol) ▪ Ethosuxamide ▪ Lamotrigine (Lamictal) ▪ Topiramate (Topamax) ▪ Gabapentin (Neurontin) ▪ Clonazepam ▪ Levetiracetam (Keppra) ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Pancreatitis LFT abnormalities Leukopenia, thrombocytopenia Aggressive behavior Stevens-Johnson syndrome (2) Gum hyperplasia Metabolic acidosis Sleep disturbance Exacerbates JME Poor concentration Sedation (3) Trouble finding words Side Effects What are goals of epilepsy therapy in pregnancy? Seizures & pregnancy The A-B-C’s of Seizure Intervention ▪ Airway ▪ Recovery position ▪ Breathing ▪ Assess & protect airway ▪ Circulation, Crash Cart & head ▪ Dextrose ▪ Attach pt to a ▪ Electrolytes cardiopulmonary ▪ First Line Abortive monitor Medication Vital signs (get RN in ▪ Get Help If not yet done! room) ▪ Additional history ▪ Notify senior resident/med consult, etc Case 1 Review Go Back ▪ Metabolic ▪ ▪ ▪ ▪ ▪ ↓ Calcium ↓ Glucose ↑ or↓ Sodium Hyperthyroidism Dialysis disequilibrium syndrome ▪ [↓ Magnesium (severe)] ▪ [Nonketotic hyperglycemia] ▪ Trauma ▪ Post-concussive ▪ Intracranial hemorrhage ▪ Space-Occupying Lesion ▪ Tumor/Mass ▪ Brain mets ▪ CNS lymphoma ▪ Toxoplasmosis ▪ AVM ▪ Infection ▪ Encephalitis +/- meningo ▪ Neurocysticercosis ▪ Brain abscess/perimeningeal ▪ Psych ▪ Pseudoseizures ▪ Epilepsy/Seizure Disorder ▪ Cardio-Respiratory ▪ ↑ ICP ▪ Hypoxia/anoxia ▪ Crytococcal meningitis Differential Dx of Seizures ▪ Toxins/Medications ▪ CNS Stimulation ▪ Cocaine/Amphetamines ▪ Withdrawal from agents ▪ ETOH ▪ Opioid ▪ Benzo ▪ GHB ▪ Decreased threshold ▪ Wellbutrin ▪ Haldol ▪ Tramadol ▪ Imipenem Differential Dx of Seizures Overview Review Case 2 Agents that Can Induce Seizures Treatment Risk Factors ▪ Meningoencephalitis ▪ History of childhood febrile seizures ▪ History of head trauma ▪ Family history of epilepsy Review Treatment QUESTIONS?
