SEIZURES Dr Zolfaghari Assistant Professor of Emergency Medicine

SEIZURES Dr. Zolfaghari Assistant Professor of Emergency Medicine Dr. Farahmand Rad Assistant Professor of Emergency Medicine

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.

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.

CLASSIFICATION OF SEIZURES v o o Generalized seizures (consciousness always lost) Tonic colonic seizures (grand mal) Absence seizures (petit mal) Myoclonic seizure Atonic seizures

CLASSIFICATION OF SEIZURES v Partial o (focal) seizures: Simple partial no alteration of consciousness o Complex partial consciousness impaired o Partial seizures (simple or complex) with secondary generalization

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

STATUS EPILEPTICUS � Continuous seizure activity lasting for at least 5 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 whethere 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, 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: 1) Airway: � Oxygen � Pulse oximetry � Endotracheal intubation � for � If prolonged seizure RSI is performed, a short acting paralytic agent should be used so that ongoing seizure activity can be observed

TREATMENT: 2) Breathing: � Suction � Airway adjuncts 3) Circulation: IV access � IV glucose if confirmed hypoglycemia

STATUS EPILEPTICUS Continuous seizure activity lasting for at least 5 min, or two or more seizures without intervening return to baseline � Continuous seizure activity for >5 min should be treated (most seizures last 1 -2 min) � Impending SE if >3 tonic - colonic seizures within 24 hrs 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 (NPA, OPA, ETT). If RSI is required, use short acting paralytics. � Obtain IV access � Blood glucose � Cardiac monitoring

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 6 month to 5 years � Identify and treat cause � Acetaminophen, ibuprofen and tepid water baths. � Family history increases risk.

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

EPILEPSY � Breakthrough seizures vs. noncompliance with medications � Precipitating factors � Infection � Drug � Treat use 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 monitoring

NO LONGER SEIZING: Recovery position � IV � Blood glucose � Medication history �

IS SEIZING STILL Airway assessment (PA, suction) � 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 �

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 � high risk for aspiration � oxygen � IV access � Immediate glucose testing or D 50 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 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?

CASE 2 � 19 year old healthy female breast feeding a newborn has a tonic-clonic seizure � PE? � Dx? � treatment?

CASE 3: � 50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on tegretol. � PE? � Dx? � Treatment?

CASE 4: � 34 yo male with hx of alcoholism found s/p seizure. � Pt is confused and combative. � Vomiting.

CASE 5: � 22 yo female with 2 episodes of “shaking” in last 6 hours with active seizing for 15 minutes. � PE? � Dx? � Treatment?

Questions? ?