Seizures and SE in Adults PDF

SEAZURES AND SE IN ADULTS TAMAR SARIA INTRODUCTION AND DEFINITION A seizure is an episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons Epilepsy is a clinical condition in which an individual is subject to recurrent seizures Primary, or idiopathic, s...

SEAZURES AND SE IN ADULTS TAMAR SARIA INTRODUCTION AND DEFINITION A seizure is an episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons Epilepsy is a clinical condition in which an individual is subject to recurrent seizures Primary, or idiopathic, seizures are those in which no evident cause can be identified. Secondary, or symptomatic, seizures are a consequence of an identifiable neurologic condition, such as a mass lesion, previous head injury, or stroke  1. status epilepticus is seizure activity for ≥5 minutes or two or more seizures without regaining consciousness between seizures SE 2. refractory status epilepticus is persistent seizure activity despite the IV administration of adequate amounts of two anti epileptic agents.  The International League Against Epilepsy recommends dividing sei zures into two major groups: generalized seizures and partial seizures Generalized seizures (consciousness SEIZURE always lost) Tonic-clonic seizures (grand mal) CLASSIFICATION Absence seizures (petit mal) Others (myoclonic, tonic, clonic, or atonic seizures) Partial (focal) seizures Simple partial (no alteration of consciousness) Complex partial (consciousness impaired) Partial seizures with secondary generalization (Jacksonian march) Unclassified (inadequate information) GENERALIZED SEIZURES 1. 2. Consciousness is always lost. Absence seizures PARTIAL (FOCAL) SEIZURES In simple partial focal seizures, the seizure remains localized, and consciousness and mentation are not affected. Complex partial seizures are focal seizures in which consciousness or mentation is affected Symptoms may include automatisms, visceral symptoms, hallucinations, memory disturbances, distorted perception, and affective disorders CLINICAL FEATURES FEATURES presence of a preceding aura, abrupt or gradual onset, progression of motor activity, loss of bowel or bladder control, presence of oral injury, and whether the activity was localized or generalized and symmetric or unilateral  Common precipitating factors include missed doses of antiepileptic medications; recent alterations in medication, including dosage change or conversion from brand name; sleep deprivation; increased strenuous activity; infection; electrolyte disturbances; alcohol or substance use or withdrawal. PICTURE #1  Common Causes of Provoked (Secondary) Seizures TRAUMA (RECENT OR REMOTE) INTRACRANIAL HEMORRHAGE (SUBDURAL, EPIDURAL, SUBARACHNOID, INTRAPARENCHYMAL) STRUCTURAL CNS ABNORMALITIES VASCULAR LESION (ANEURYSM, ARTERIOVENOUS MALFORMATION) MASS LESIONS (PRIMARY OR METASTATIC NEOPLASMS) DEGENERATIVE NEUROLOGIC DISEASES CONGENITAL BRAIN ABNORMALITIES INFECTION (MENINGITIS, ENCEPHALITIS, ABSCESS) !!! A transient focal deficit (usually unilateral) following a simple or complex focal seizure is referred to as Todd’s paralysis and should resolve within 48 hours.  Continued… Metabolic disturbances Hypo- or hyperglycemia Hypo- or hypernatremia Hyperosmolar states Uremia Hepatic failure Hypocalcemia, hypomagnesemia (rare) Toxins and drugs (many) Cocaine, lidocaine, antidepressants, theophylline, isoniazid Mushroom toxicity (Gyromitra spp.) Hydrazine (rocket fuels) Alcohol or drug withdrawal Eclampsia of pregnancy (may occur up to 8 weeks postpartum) Hypertensive encephalopathy Anoxic-ischemic injury (cardiac arrest, severe hypoxemia) PAROXYSMAL DISORDERS: DIFFERENTIAL DIAGNOSIS Seizures Syncope Pseudoseizures or psychogenic seizures Hyperventilation syndrome Migraine headache Movement disorders LABORATORY TESTING In a patient with a well documented seizure disorder who has had a single unprovoked seizure, the only tests that may be needed are a glucose level and pertinent anticonvulsant medication levels. IMAGING Concern for an acute intracranial process is an important indication for obtaining CT imaging, even if there is a coexistent metabolic process  LUMBAR PUNCTURE Lumbar puncture in the setting of an acute seizure is indicated if the patient is febrile or immunocompromised or if subarachnoid hemorrhage is suspected and the noncontrast head CT is normal  Emergent EEG can be considered in the evaluation of a patient with persistent, unexplained altered mental status to evaluate for non convulsive status epilepticus, subtle status epilepticus, paroxysmal attack when a seizure is suspected, or ongoing status epilepticus after chemical paralysis for intubation. EEG TREATMENT OF UNCOMPLICATED SEIZURES It is not necessary to give IV anticonvulsant medications during the course of an uncomplicated seizure. Most seizures will self-resolve within 5 minutes. Any unnecessary sedation at this point will complicate the evaluation and result in a prolonged decrease in level of consciousness Obtain a serum anticonvulsant level before administering a supplemental or loading dose to avoid drug toxicity. If anticonvulsant levels are adequate and the patient has had a single attack, specific treatment may not be needed if the seizure pattern and frequency fall within the expected range for the patient. PATIENTS WITH A FIRST UNPROVOKED SEIZURE Guidelines do not recommend hospital admission or initiation of anti convulsant therapy in the patient with a first unprovoked seizure, as long as the patient has returned to neurologic baseline In general, patients with a first unprovoked seizure who have a normal neurologic examination, no acute or chronic medical comorbidities, normal diagnostic testing including noncontrast head CT, and normal mental status can safely be discharged from the ED. NEUROCYSTICERCOSIS Neurocysticercosis is caused by a CNS infection with the larval stage of the tapeworm Taenia solium and is the most common cause of provoked (secondary) seizures in the developing world PREGNANCY When a woman beyond 20 weeks of gestation develops seizures in the setting of hypertension, edema, and proteinuria, the condition is defined as eclampsia. Magnesium sulfate has long been used to treat eclampsia with good results ALCOHOL ABUSE Seizures and alcohol use are associated through: missed doses of medication, sleep deprivation as an epileptogenic trigger, increased propensity for head injury, toxic co-ingestions, electrolyte abnormalities, and withdrawal seizures. SE Status epilepticus is a single seizure ≥5 minutes in length or two or more seizures without recovery of consciousness between seizures Pathophysiology of SE The blood–brain barrier is compromised CNS penetration of potassium and albumin INCREASED both of which are hyperexcitatory CNS chemicals. After 20 minutes - hypotension, hypoxia, metabolic acidosis, hyperthermia, and hypoglycemia are present. Additionally, cardiac dysrhythmias, rhabdomyolysis, and pulmonary edema can develop. After 2 hours of seizure activity, neurotoxic amino acids and calcium are released into cells, leading to permanent neuronal necrosis and apoptosis. Nonconvulsive status epilepticus Patient is comatose or has fluctuating abnormal mental status or confusion, but no overt seizure activity is present. The diagnosis is challenging and is typically made by EEG TREATMENT OF STATUS EPILEPTICUS QUESTIONS?