neuro4 seiz

8/12/2019 Neuro4 seiz

1/16

Neuro 4

Seizures,Headache, Itis etc

Leah Kelly

Future

Will use more agents to salvage cells and elim oxygen derived free radicals

So use scavengers and antioxidants glutamate antagonistsNerve gro!th factors and do neural trans"lants

Kee"ing core #ody tem" under $% degrees for %4 hrs

Neuroscience Futures

&s noted "reviously

less invasive, less time

'a" out #rain areas and use "ro#e

&lso using laser and gamma (nife for radiosurgery

)* shunts are im"regnated !ith anti#iotics to guard against infection valve

"ressures can #e re"rogrammed

Im"lanta#le devices

No! many "rogramma#le devices to deliver analgesics or antis"asmodics to +SF mor"hine- or .aclofen s"asticity-

+an "lace a remote control over s(in to titrate dose

&lso loo(ing at im"lanting neurotro"hic gro!th factors

&lso doing visual / auditory im"lants in areas of #rain !here deaf or #lind

Seizures

Initially thot victims sacred then "ossessed

No! as chronic disorder of recurrent electrical discharge

Seizure is transient change in #ehavior r0t discharge of certain neurons

1enetic, develo"mental, trauma, +NS infection, &)', tumor, stro(e, degenerative

disease

2%3 #illion cost in direct0indirect costs256 of "o"ulation !ith one seizure in lifetime

Seizures

26 of "o"ulationas a result "atients have emotional and social stressors and

monetary #urden

Family mem#ers !ith fears still in closet

No! as many in over 75 as *edi

&n ele"togenic focus activated #y tem"erature change, hy"oxia, decreased sodium,

decrease sugar, light stimulus

8"ile"sy defined

Syndrome of recurrent un"rovo(ed seizures

Seizures are sudden e"isodes of neurological dysfunction caused #y a#normal #rain

electrical activity

% different (inds

&lso are "sychogenic seizures

Hysteria, rarely cry or laugh or thrust

If you can sto" a lim# #y holding not neuro

8yes are o"en in real seizure if eyes shut !onder


2/16

Seizures are stereoty"ical

Seizures

$ grou"s

Well controlled so 9ust !atch not too much meds !atch side effects 56

'oderately controlled $56Not controlled no matter !hat com#ination

So for some the issues are grave

Ho! to chart a seizure

*rodromal "hase oft a!ait it is coming headache, aura, tingly, irritated

&ura smell, light, sound, automatism hel"s localize

8"ile"tic +ry from the air movt related to an a#dominal s"asm

Ictal !hat ha""ens in seizure

*ost Ictal !hat ha""ens after the seizure

*atho"hysiology of seizures

Some trigger causes #urst of electrical stimulation

:isru"ts normal nerve conduction via a#normal de"olarization'alfunction of hy"ersensitive neurons in cortex and oft lim#ic system !here more

hy"ersensitive neurons

*atho"hysiology of seizures

'alfunction of hy"ersensitive neurons in cortex and oft lim#ic system !here more

hy"ersensitive neurons

Stimulus is "hysiologic odor, music, noise, startle, ;), lights

So medical management !ill eliminate focus either meds, surgery

Seizure ;erms

;onic state of muscular contraction 0or rigidity voluntary muscles contractednly 256 are this ty"e

:uration usually a#out $ minutes in tonic are stiff0rigid then follo!ed #y clonic

9er(ing !hen are cyanotic and a"neic

+an occur daily, monthly or yearly

Lasts % minutes and then are "ostictal or unres"onsive

+ould slee" for several hours

&l!ays tired, de"ressed / confused after!ard

1rand 'al

;onic "hase

shrill cry !ith rigidity, o"isthotonos, arms extended, "u"ils dilated and

unreactive, decreased heart rate

+lonic "hase

#egins and ends suddenly

Euic( #ilateral 9er(ing movements that last only a minute or so

*ost Ictal

'uscles flaccid, consciousness returns gradually, amnesia a#out seizure

'yoclonic / &tonic

'yoclonic Short single a#ru"t muscle contractions

&tonic loss of muscle tone and dro" to floor so ris( for in9ury

*seudoseizures

+linical "resentations of seizureli(e #ehavior not accom"anied #y a#normal 881s


5/16

>ft seen in "sych hx of !ith a#use, #ulimia

>ft triggered #y stressful situations usually only !hen others "resent oft "elvic

thrusting, crying, disoriented

>ft hard to diagnose may occur !ith e"ile"sy

:o not #ecome incontinent

*seudo or *sychogenic seizures %not necessarily under voluntary control the secondary gain is not al!ays a""arent

;hese "ts need anxiolytics and antide"ressants

High correlation to "hysical and sexual a#use

'ay also have real seizures

&fter real seizures !ill have very high "rolactin levels if dra! #lood !ithin 2

minutes

Status 8"ile"ticus

'8:I+&L 8'818N+G

+ere#ral meta# rate is $normal so get edema

No recovery to #aseline so continual discharge and #uild u" of acidosis

1et a line NS- and air!ay stat did "t ta(e meds1et lytes, .=N, glucose, &8: drug levels, tox screen

Longer it lasts more use of glucose more danger of I+*

Status

&ctivity lasts $5 minutes could #e tonic clonic or even "artial, sensory, a#sence

>ft ha""ens !ith sto""ing of anticonvulsants

+lear air!ay turn to side "re"are to intu#ate

'eds for Status 8"ile"ticus

&tivanloraze"am,-occasionally )alium or "heno#ar# also may#e muscle

#loc(ade

&tivan#etter than valium coz less li"id solu#le and longer halflife drug of

choice 4 mg I)

:ilantin is not sedating #ut can irritate and give this after the #enzo hy"otension,

Seizure meds

+ere#yx fos"heytoin !hich #ecomes :ilantin in 2 min #ut can give faster than

:ilantin #ut no local irritat #eyond "erineal "aresthesias %5 mg0(g at 25

mg0min

Fe#rile +onvulsions

Seizures that occur during e"isodes of high fever often in early childhood

See in 6 of all (ids

If localized and last longer than $5 minutes increased ris( of e"ile"sy

+an "revent !ith anti"yretics

8;>H !ithdra!al

In $$6 of heavy drin(ers @$5 hrs " sto" 8;>H

Will continue 4hrs

:; $4 days J !ith agitation, hallucinations / autonomic insta#lity

Will give )*& #ut not effective

8lderly

Highest incidence of ne! onset


6/16

&fter stro(, head trauma, dementia, 8;>H

'onothera"y at lo! doses

Ho! does med affect "t

Seizure +ausation

From +NS infections, oral a#cess, neurosurgery, ear infections

.rain trauma contusions, lacerations, hematoma>ften first sign of #rain tumors cause irritation to cortex

>ft occur in clusters from drug induction, concurrent illness

So a seizure !or(u"

&ll get same testing

H !hat are "reci"itants fever, in9ury, slee" de"rivation, drugs, hy"erventilation

1et +;, S(ull ray, #lood glucose, lytes, calcium ,

881 to locate focus and identify ty"e

>ften !ill need to go to an e"ile"sy monitoring un it

;ime synched digital video !ith a digital 881

Seizure +are

Never leave alone and "rotect from in9ury*rovide "rivacy

If out of #ed ease to floor and "rotect head

Loosen clothing roll to side to "revent as"iration

:onDt force air!ay

;hen remain calm and reorient

+harting in Seizure

>nset !hen, !hat doing, !hat accom"anied, automatisms, cry etc

:uration exact timings, !hen head turned, !hen "ost ictal, incontinent

'otor activity "rogression, rigidity, 9er(ing, eyes and tongue

L>+ is arousa#le +an tal( :istracti#le

*u"ils ;eeth clenched es"irations +ontinence

;hen note changes for su#seuent timeframe

Seizure 'eds &8:s

&ll sta#ilize cell mem#rane #y altering trans"ort of Na, K, +a

educe res"onse to incoming stimuli, reduce s"read, etc

Need holistic a""roach to find the #est

;hin( (inetics, side effects, serum levels, halflives

Worry a#out Status 8"ile"ticus in "regnancy and times of stress

&ll < dro!siness, sedation, allergy, 1I u"set

Ne! meds oft so story !ill change

.asic 'eds

1rand 'al :ilntina, ;egretol, :e"a(ene, *heno#ar# generics-

*heno#ar# is dulling

sence8thosuximide, :e"a(ote, Klono"in

+om"lex0Sim"le *artialM ;egretol, :e"a(ote, :ilantin

;rile"tal, Ke""ra, onegran

>ft large loading doses give til get side effects !atch serum levels

Loo( at #lood level correlated !ith clinical res"onse

&nticonvulsants


7/16

What has least side effects

Ne! variants !ith less effects :ilantin< ne! Fos"hentoin

:ilantin !ith #ig gums, hairy, thic( s(in

;egretol no! extended relief L

'ysoline, :e"a(ene, :e"a(ote, Klono"in, arontin,

1a#a"entin, Lamictal 'ysoline:e"a(ote is good for all of the seizures #ut hair lossand !eight gain

Ne!er 'eds

Lamictal augmenting, !orry Stevens Cohnson syndrome

Sto" at first sign of rash

1a#a"entin Neurontin also for "ain, mood, fe! drug drug interaction

;o"iramate ;o"amax- mess !ith cognition, s"eech

;rile"tal li(e ;egretol #ut not autoinduction so stay more clear, no "45 enzymes

+an ta(e .iaxin

*otiga

Seeing more no! than older ones

*otiga ezoga#ine-


8/16

Stay calm and chec( for medialert #racelet

;ime the seizure

sence time and re"ort

;onic clonic turn on side and cushion head remove glasses and o#9ects

:uring Seizure

*lace on side to "revent as"irationHead tilt chin lift maneuver to facilitate air!ay "atency

Nothing in mouth if arrive after seizure #egins

;onic clonic

Note "osition

*atient 8ducation

*atients and family mem#ers

educe exacer#ating factors 8;>H, stress, consti"ation, diarrhea, slee"

de"rivation, flashing lights

Non com"liance !ith meds canDt drive unless seizure free for 2 year

;each family !hat to do "rotections

1o to 8 if "rolonged seizure activity maintain seizure calendar>n admission

&s( !hat seizure is li(e

:id you ta(e your meds today ho! !ell are you controlled

Let me (no! if feel aura, or "rodromal

Ho! !ould you "ad rails

&ir!ay at #edside

educe stimulation

8"ile"sy 8valuation

Loo( at medical Hx3, freuency / character of seizures

+ontinuous 881 monitoring, drug levels, scans and neuro"sych

Slee" on #lue sheets !ith continuous monitoring

>ft monitor tech to !atch 0family

'ay !ithdra! &8:s antie"ile"tic drugs

"lace s"henoid electrodes, +;, 'I, S*8+;, W&:&

+ontinuous 881

>ver %$ scal" electrodes held on !ith colloidin no crPme rinse

>cc im"lant su# s(in in s"henoid area

;hen :+ or ta"er seizure meds get to hy"erventilate or exercise

Neuro"sych eval c hand eyememory, conc, attent, s"atial

So also !ill need #aseline cognitive function in case of loss "ost o"

Im"lications

So you never leave then alone centers have cameras

:riving restrictions must #e 2$ years seizure free

No s!imming alone, !atch #i(e, "o!er tools

Sho!er vs3 tu#

'edic alert

&void alcohol, avoid coffee, !atch fatigue, consti"ation

Seizure Surgery

% million &mericans are victims


9/16

2022 !ill have a seizure sometime

Surgery is o"tion for 25%6 of "artial seizure ty"es es"3 tem"oral lo#e

Will locate seizure focus to see if can safely resect

=su3 done at com"rehensive e"ile"sy ctr3

)agal Nerve Stimulator

*acema(er li(e "ulse generator !hich gives intermittent stimulation %4 hrs day0 on$5 secs off min

.attery life of 2% yrs

Seems to sto" the seizure via retrograde stimulation

;hey can activate it on demand !hen ex"erience and aura

Ketogenic diet

Ketosis as formation of (etones so this diet maintains this as in &t(ins to alter use

of car#s as #ody fuel

Seems to "revent seizures in some (ids

+oming

8arly !arning devices that monitor #rain for change leading to seizures

8"ile"sy +ontrol System 'edtronic closed loo" systems !ith microchi"s toanalyze li(e "acer li(e I+:s tiny eeg !hen see a#norm activity send message

to ant nucleus in thalamus so this !ill send counte!aves via electrodes

In trials S&N;8 trial

Infections

.acterial, viral, fungal, "arasitic

+lass #y !here occur or #y ty"e of organism

&ll itises are diffuse #rain issues so have generalized sym"toms

Watch for I+* from increased #lood volumeincreased tissue #ul(

+an come on ra"idly or more slo!ly

+are in itises

Isolate the "ro#lem and give anti#iotic or antiviral on time

&ssess / treat for I+* cool, hy"erventilate, oxygenate

*rotect from in9ury

Linen changes, fluid 0lyte status

Isolation

Watch com"lications #edrest !atch for "osturing

:ar(, uiet room, meningeal irritation

'eningitis

Is inflammation of meninges!ith s!elling, change in neuro signs

Inflammation of arachnoid, "ia, dura

If hit #rain then also cord coz meninges

Ho! does organism get in #lood, trauma, mouth, nose colonizes #y dro"let or

contact

.acterial or viral

>nce form exudate inflames and changes arteries

'eningitis

'eningitis

2Q255,555 can #e ra"idly fatal des"ite anti#iotics college students high ris(

*ro"hylax close contacts !ith rifam"in, ci"ro or ceftriaxone


10/16

Ne! meningitis vaccine tetravalent 'enactra

'eningitis

medical emergency"isthotonos

*etechial rash

.rudzins(i

Kernig

.acterial 'eningitis

'ost commonly in childhood serious and lethal in 2st year

Hard to "ic( u"

&ny #acterium is causative #ut orgs are "articular to age

S/S vary !ith age, organism, duration

+ommunica#le til no cocci "resent in discharge

.acterial meningitis

S vague irrita#le, vomit, lethargy, anorexia, fever

headache, ;25225$, confusion may seize

need anti#iosis immediately

anti"yretic coz shiver increases #rain meta#olism

'a(ing :x of #acterial 'eningitis

*neumococcus

+SF "ressure is elevated / too cloudy

+SF !ill have "rotein, increased W.+s, decreased sugar

Need s"eed of treatment can die !ithin 2% hrs

&nti#iotics< hi doses and give on time

ifam"in or other that crosses #lood #rain #arrier

)iral 'eningitis

&lso called ase"tic usu $ days "rodromal

>ft is +oc(sac(ie or oral0fecal s"read


11/16

See headache, fever, normal glucose in +SF

No meds here although Symmetrel, oviraxes

Intervention )iral 'eningitis or .acterial

comfort for restless, irrita#ility, "hoto"ho#ia

"rivate room if #acterial !hat is an isolation room

limit visitors, little movt s"ace activities, sedate&deuate nutrition and fluids ma(e sure I) is on time

*o"sicleRs, !t, I/>, lytes

su""ortive care rest and slee"

Seuelae meningitis

if viral it is su""ortive care

seuelae otitis, hydroce"halus, deafness, retardation, seizures

)accine 'eningitis

)accines r ; cell inde" stim mature lym"hocytes

Ne! vaccine is 'enactra and still is 'enomune hits most of grou"s #ut no good in

(ids under %2 su# E dose 53 ml can get "ain at site

8nce"halitis

can #e viral, #acterial, fungal, "arasiticmost viral

fulminating fe#rile disease rare #ut fatal

)iral as !estern euine, "olio, cytomegalo, +oc(sac(ie, her"es ence"halitis

her"es as "rimary, reinfection or activation of latent infection

her"es in aids "atient 56

S !orse if older or cold climate

%6 of "o"ulation have HS)2 as a cold sore attac(s "reci" #y stress, fever, sun,

etc

8nce"halitis

:N& from #ody fluids re"licates in cell nucleus

can #e localized or travel

;a" #acterial is clouded viral is clear

initial +; !ill #e negative

days !ill get mass effec

: of 8nce"halitis

HS) virus no! v is "olymerase chain reaction test to +SF may see increase

"rotein and increased +SF "ressure

; of viral ence"halitis

need to treat &S&* to "revent neuro damage

I) acyclovir for @24 days

early ;x !ill result in survival

can still get com"lications and residual damage

headache, fatigue, tremors, seizures

ma9or nsg :x is altered cere#ral tissue "erfusion

may :ilantin load to !hy

Her"es ence"halitis

HS) latent in trigeminal nerve


12/16

travels to middle / ant #rain in tem"oral and or#ital cortex

lyses neuron 0 alters mitochondria, (ills cell

get hemorrhage, cere#ral edema, I+*consciousness / "u"il change, delirium, coma

< herniation

signs de"end on area of #rain infected

Her"es ence"halitisinitially loo( li(e flu< headache, malaise, fever / vomiting

memory im"airment / "ersonality change if get frontal lo#e

dementia from degeneration of nerve cells !ith cognitive slo!ing

tem"oral lo#e !ith terror, auditory, visual or olfactory hallucinations,ne!

aggression

seizures, hemi"aresis, a"hasia, visual field defects

Headaches

Gour does this !ell so read it text

;ension

:ull achy, #ilateral tight head and nec(

Start slo!ly, middle of day a stress headache'ild mod to severe muscle contraction *'S, middle age, remove source of

stim

>;+ "re"s !or( !ell also heat, ice"ac(, sho!er, slee", exercise

Headaches

+luster headache+luster headache

are, more common in men, starts suddenly

*ain #ehind eye, excruciating

Nose and eye on side get red, s!ollen

Last a#out 4 mins same time each day for 4 !ee(s

un in family in a cluster "eriod r0t smo(ing

&lcohol can exacer#ated

8yes #ulge even !ith "tonsis

&utonomic features

;reat !ith meds and a shot or inhalation med

Infovin, Lithium, .eta#loc(ers

Headache as Inflammation

see

'igraine

Lots of ne! stuff here and ne! meds #oo( is out of date changes in serotonin

!hen hi vessels shrin( !hen lo!, vessels s!ell and cause "ain

'igraine oft under treated and underdiagnosed hard to ma(e :x

'igraineurs

+hronic disease @56 have genetic association usu #egins in childhood or

adolescence "ea(s in mid 45Ds

'a9or im"act on !or(ers

'igraine

syndrome of "rolonged "ainful headache and disa#ling autonomic sym"toms !ith

nausea / vomiting


13/16

;hro##ing, dull "ain on one or #oth sides

;ummy ache or vomit

&nnoyed #y noise, light, smells,

;ired, confused, stuffy nose

Stiff nec(

:izzy+lassic !ith aura, of 2 or so minutes, common do not

'igraine 'nemonic Sultans

Severe

=nilateral

;hro##ing

&ctivity !orsens

With Nausea

With light sensitivity

&ura< reversi#le, gradual,

'igraine"ain

Sym"toms of 'igraine

*rolonged "ainful headache !ith eually disa#ling autonomic Sx3 li(e N/)

With or !ithout aura or "rodrome

Without aura most common unilateral "ulsatile , "hoto"ho#ia, hy"er react to

sound and smell

*rodrome os de"ression, eu"horia, irrita#le, restless, still

'igraine !ith aura

)isual distur#ance !ith scintillating lights or scotoma, hemi"aresis, hemisensory

issues, a"hasia

;riggers are caffeine, stress, lac( of slee", exertion, menses, 8;>H

'igraine

tt"Q00!!!3youtu#e3com0!atchvMyrCoe!g

htt"Q00!!!3youtu#e3com0!atchvMl1C%C.H'

;riggers of migraine

&ged, cured meat hot dogs, lunch meat

&ged cheese

ed !ine

&s"artame

&vocado

.eans

+affeine, chocolate

Sour cream, #uttermil(

Figs, 'S1, nuts, "eanut #utter

>nions, "a"aya

*assion fruit, "ea"ods

>lives, "ic(les

aisins, red "lums

Sauer(raut


14/16

Sno! "eas

Soy sauce

*athogenesis of 'igraine

$ different theories "ro# a #it of all $

)ascular< !ith reactive "ainful vasodilation, "erivascular inflammation

Neurogenic inflammation neuro"e"tide released to "erivascular inflammation=nsta#le serotogenic neurotransmission serotonin is an inhi#itor and stim rece"tors

"ro#a#ly leads to release of inflammatory mediators

8ffect of drug over usage

Narro! !indo! 9ust at headache onset that migraine meds !or(

If miss this then !ill #e in futile catchu" mode

;hen get refractory headache !h is chronic re#ound, or daily headache

&lso get tolerant to the sym"toms and the meds

Non *harmaceuticals

i#oflavin 455mg-, chelated magnesium, Feverfe!

Slee" and meals, #iofeed#ac(, massage, acu"uncture, hy"nosis

'gmt drugs*ro"hylactic agents M antagonists of H; serotonin sta#ilize ions, inflammation

ortive agentsMagonists of the rece"tors

Need early treatment / high enough dose

So Narcotic analgesics, NS&I:3 8rgot get re#ound must ta(e immediately

and can coz nausea

:H8 dihydroergotamine < venoconstrictor T a long half life / no ris( of

addiction or re#ound

Will soon #e availa#le as a nasal s"ray

ortive ;hera"y in 8

I) ;oradol

I) ;horazine

I) :H8 ergot

S+ Imitrex

*henergan or +om"azine

;ri"tans / .eta .loc(ers

No! of them H;2.02: agonists

)asoconstriction su""ress nause, confusion

Sumatri"tan Imitrex-,olmitri"tan, omig-izatri"tan 'axalt-, Naratri"tan

&merge-, &lmotri"tan &xert-, Fravatri"tan Frova-

el"ax and &xert are long acting

. #loc(ade

Inderal LS

&nticonvulsants ;o"amax may#e )*&, Neurontin

;ri"tans

Li(e Imitrex this is a H;2 agonist that is nonsedating oral, su#, or in9ect

:oesnDt modify cere#ral flo!

Has intrinsic antiemetic effect

Wor(s in minutes

@56 recover in 2 hr 56 in % hrs


15/16

:onDt have to ta(e early and give after aura !hen "ain #egins

Wor(s on "ain, N/), "hoto"ho#ia

= stay alert, no re#ound headache

;ri"tans

+anDt use these in +&:, H;N or those on SSI coz !ill get serotonin syndrome

Some are ta#s, others dissolveNaratri"tan has a long halflife and fe! side effects

>ther meds

+odeine0fiorinal are out of date and dangerous

Narcotics are only moderately effective and sedating

&ctually increase nausea

.eta .loc(ers

Not good for "ro"hylaxis

:e"a(ote

No! a""roved for "ro"hylaxis coz is a 1&.& agonist reduces do"amine,

;o"amax

;etanuslifethreatening #ut com"letely "reventa#le usu "uncture !ounds and lacerations

usu in elderly in nonimmunized

incu#ates %O !ee(s

clostridium tetanii gram "ositive, s"ore forming anaero#e soil0dust 0!ater

"roduces neurotoxin that causes s(eletal muscle hy"ertonicity

;etanus %

enters thru !oundM s"ores can lie dormant til activate to "roduce a tetanolysin !h

affects the autonomic NS

!ith cardiac dysrythmias, unsta#le .* and "ro#lems of "ulse and fever

tetanos"as"asmin #loc(s neurotransmitter &+H / disinhi#iting the s"inal cord

reflex arcs so that you get uncontrolled tetanos"asms

;etanus %

o"isthotonus from s"asm of #ac( and nec(

canRt ma(e enuf antitoxin so must have immunization loc(9a!, hy"errigidity,

hy"erreflexia, dys"hagia, 1I dysfunction, cardiac dysrythmias

;etanus $

air!ays < laryngos"asm com"romise in res" failure, thus lungs at issue

may need intu#ation / #enzodiaze"ines to give neuromuscular #loc(ade

also give ;acrium neuromusc #loc(ing agent and (ee" "aralyzed

same idea of dar(, nonsimulating environment, analgesia and anxiolytics

;etanus $

since affects sym"athetic NS !ill get unsta#le rate, rhythm / fever

!atch immo#ility, de#ride !ound

tetanus immune glo#ulin$55 units I' at intervals to neutralize any toxin left in

#ody


16/16

idea is #ooster E 25 years for life

.rain a#cess

residue or infection, meningitis, ence"halitis

neuro4 seiz

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