SeizuresSeizures

Soma Pathak, MDSoma Pathak, MD

PGY-2PGY-2

Emergency MedicineEmergency Medicine

OverviewOverview

DefinitionDefinition EpidemiologyEpidemiology Clinical FeaturesClinical Features Differential DiagnosisDifferential Diagnosis TreatmentTreatment CasesCases

DefinitionsDefinitions

Seizure: episode of abnormal Seizure: episode of abnormal neurologic function caused by neurologic function caused by inappropriate electrical discharge inappropriate electrical discharge of brain neurons. of brain neurons.

Epilepsy: clinical condition in Epilepsy: clinical condition in which an individual is subject to which an individual is subject to recurrent seizures. recurrent seizures.

EpidemiologyEpidemiology

100,000 new cases of seizures 100,000 new cases of seizures diagnosed in the US each yeardiagnosed in the US each year

Incidence of seizures world-wide is Incidence of seizures world-wide is 30.9 to 56.8 per 100,000.30.9 to 56.8 per 100,000.

Highest rates among those less than Highest rates among those less than 20 years old followed by those over 20 years old followed by those over 60.60.

Male>FemaleMale>Female

Generalized SeizuresGeneralized Seizures

Caused by a Caused by a nearly nearly simultaneous simultaneous activation of the activation of the entire cerebral entire cerebral cortexcortex

Partial seizuresPartial seizures

Due to electrical Due to electrical discharges in a discharges in a localized localized structural lesion structural lesion of the brain.of the brain.

Affects whatever Affects whatever physical or physical or mental activity mental activity that area that area controls. controls.

Partial (focal) seizuresPartial (focal) seizures

Simple partial Simple partial no alteration of consciousnessno alteration of consciousness

Complex partial Complex partial consciousness impairedconsciousness impaired

Partial seizures (simple or Partial seizures (simple or complex) with secondary complex) with secondary generalizationgeneralization

Classification of Classification of SeizuresSeizures Generalized seizures Generalized seizures

(consciousness always lost)(consciousness always lost) Tonic clonic seizures (grand mal)Tonic clonic seizures (grand mal) Absence seizures (petit mal)Absence seizures (petit mal) Myclonic seizureMyclonic seizure Clonic seizuresClonic seizures Atonic seizuresAtonic seizures

Causes: secondary Causes: secondary seizuresseizures Trauma (recent or remote)Trauma (recent or remote) Intracranial hemorrhageIntracranial hemorrhage EclampsiaEclampsia Hypertensive encephalopathyHypertensive encephalopathy Structural abnormalitiesStructural abnormalities

– Vascular lesion (aneurysm, AV Vascular lesion (aneurysm, AV malformation)malformation)

– Mass lesionMass lesion– Degenerative diseaseDegenerative disease– Congenital abnormalitiesCongenital abnormalities

Causes: secondary Causes: secondary seizuresseizures Toxins and drugsToxins and drugs Anoxic brain injury Anoxic brain injury Metabolic disturbancesMetabolic disturbances

– Hypo or hyperglycemiaHypo or hyperglycemia

– Hypo or hypernatremiaHypo or hypernatremia

– Hyperosmolar statesHyperosmolar states

– UremiaUremia

– Hepatic failureHepatic failure

– Hypocalcemia, hypomagnesemia (rare)Hypocalcemia, hypomagnesemia (rare)

Features: generalized Features: generalized seizuresseizures

Abrupt loss of consciousness and loss of Abrupt loss of consciousness and loss of postural tonepostural tone

May then become rigidMay then become rigid With extension of the trunk and With extension of the trunk and

extremitiesextremities ApneaApnea Cyanosis Cyanosis Urinary incontinenceUrinary incontinence

Features: tonic clonic Features: tonic clonic seizuresseizures As the tonic (rigid) phase subsides, As the tonic (rigid) phase subsides,

clonic (symmetric rhythmic) clonic (symmetric rhythmic) jerking of the trunk and jerking of the trunk and extremities developextremities develop

Episode lasts from 60-90 secondsEpisode lasts from 60-90 seconds Consciousness returns graduallyConsciousness returns gradually Postictal confusion may persist for Postictal confusion may persist for

several hoursseveral hours

Features : absence Features : absence seizuresseizures Brief, usually lasting only a few seconds. Brief, usually lasting only a few seconds. Loss of consciousness without losing postural Loss of consciousness without losing postural

tone.tone. Appear confused or withdrawn, and current Appear confused or withdrawn, and current

activity ceases. activity ceases. May stare and have twitching of their eyelids.May stare and have twitching of their eyelids. Do not respond to voice or other stimulationDo not respond to voice or other stimulation Are not incontinent.Are not incontinent. End abruptly, and there is no postictal period. End abruptly, and there is no postictal period.

Clinical features of Clinical features of simple partialsimple partial Remain localized and consciousness is not Remain localized and consciousness is not

affected. affected. Unilateral tonic or clonic movements limited Unilateral tonic or clonic movements limited

to one extremity suggest a focus in the to one extremity suggest a focus in the motor cortex, while tonic deviation of the motor cortex, while tonic deviation of the head and eyes suggest a front lobe focus.head and eyes suggest a front lobe focus.

Visual symptoms often result from an Visual symptoms often result from an occipital focus, while olfactory or gustatory occipital focus, while olfactory or gustatory hallucinations may arise from the medial hallucinations may arise from the medial temporal lobetemporal lobe

Sensory phenomena, or aura are often the Sensory phenomena, or aura are often the initial symptoms of attacks.initial symptoms of attacks.

Status epilepticusStatus epilepticus

Continuous seizure activity lasting Continuous seizure activity lasting for at least 30 minfor at least 30 min

Two or more seizures without Two or more seizures without intervening return to baselineintervening return to baseline

Non-convulsive status epilepticus Non-convulsive status epilepticus is associated with minimal or is associated with minimal or imperceptible convulsive activity imperceptible convulsive activity and is confirmed by EEGand is confirmed by EEG

HistoryHistory

Careful historyCareful history Important historical information:Important historical information:

– Include rapidity of onset,Include rapidity of onset,– Presence of a preceding auraPresence of a preceding aura– Progression of motor activity (local Progression of motor activity (local

or generalized)or generalized)– Incontinence.Incontinence.

HistoryHistory

Duration of the episode and Duration of the episode and whether there was postictal whether there was postictal confusionconfusion

Contributing factors:Contributing factors:– Sleep deprivationSleep deprivation– Alcohol withdrawalAlcohol withdrawal– InfectionInfection– Use or cessation of other drugsUse or cessation of other drugs

History: first time History: first time seizuresseizures History of head traumaHistory of head trauma HeadacheHeadache Pregnancy or recent deliveryPregnancy or recent delivery History of metabolic History of metabolic

derangements or hypoxiaderangements or hypoxia Systemic ingestion or Systemic ingestion or

withdrawal and alcohol use.withdrawal and alcohol use.

Physical Exam:Physical Exam:

Injuries resulting from the seizureInjuries resulting from the seizure– such as fractures, sprains, strains, such as fractures, sprains, strains,

posterior shoulder dislocation, tongue posterior shoulder dislocation, tongue lacerations, and aspiration. lacerations, and aspiration.

Localized neurological deficitsLocalized neurological deficits– Todd’s paralysis Todd’s paralysis

Differential diagnosisDifferential diagnosis

SyncopeSyncope Hyperventilation syndromeHyperventilation syndrome Complex migraineComplex migraine Movement disordersMovement disorders NarcolepsyNarcolepsy Pseudo-seizuresPseudo-seizures

Treatment: Airway: Treatment: Airway: OxygenOxygen Pulse oximetry Pulse oximetry Endotracheal intubation Endotracheal intubation

– for prolonged seizure for prolonged seizure

If RSI is performed, a short acting If RSI is performed, a short acting paralytic agent should be used so paralytic agent should be used so that ongoing seizure activity can be that ongoing seizure activity can be observedobserved

Treatment:Treatment:

Breathing:Breathing:– SuctionSuction

– Airway adjuncts Airway adjuncts

Circulation: IV accessCirculation: IV access IV glucose if confirmed IV glucose if confirmed

hypoglycemiahypoglycemia

First Line Medication: First Line Medication: BenzodiazepinesBenzodiazepines

Midazolam (Versed) IV/IMMidazolam (Versed) IV/IM Diazepam (Valium) Diazepam (Valium)

IV/ET/IO/PRIV/ET/IO/PR Lorazepam (Ativan) IV/IMLorazepam (Ativan) IV/IM

Second line medications:Second line medications:

Phenytoin/fosphenytoin Phenytoin/fosphenytoin PhenobarbitalPhenobarbital

Third line medication:Third line medication:

General anesthesia with General anesthesia with continuous EEGcontinuous EEG

– Infusions of midazolam, Infusions of midazolam, propofol, or pentobarbitalpropofol, or pentobarbital

– Inhaled isofluraneInhaled isoflurane

First Line First Line AnticonvulsantsAnticonvulsantsDRUGDRUG ADULT DOSEADULT DOSE PEDS DOSEPEDS DOSE OTHER INFOOTHER INFO

Diazepam Diazepam .2mg/kg up to .2mg/kg up to 20mg at 20mg at 2mg/min2mg/min

.2-.5mg/kg .2-.5mg/kg IV/IO or .5-IV/IO or .5-1.0mg/kg PR 1.0mg/kg PR up to 20mgup to 20mg

CNS/CV/Resp CNS/CV/Resp depressiondepression

Onset 1minOnset 1min

Lasts 20-Lasts 20-30min (longer 30min (longer PR)PR)

LorazepamLorazepam .1mg/kg IV .1mg/kg IV max 10mg at max 10mg at 2mg/min2mg/min

**Intranasal **Intranasal use promisinguse promising

.05-.1mg/kg IV.05-.1mg/kg IV CNS/CV/Resp CNS/CV/Resp depressiondepression

Onset 2minOnset 2min

Lasts >12hrsLasts >12hrs

MidazolamMidazolam .1mg/kg IV up .1mg/kg IV up to 10mg at to 10mg at 1mg/min 1mg/min or .2mg/kg IM or .2mg/kg IM

**Intranasal **Intranasal use promisinguse promising

.15mg/kg IV.15mg/kg IV

.2mg/kg IM.2mg/kg IM

Less Less depressiondepression

Onset 1minOnset 1min

Short durationShort duration

Case 1:Case 1:

14 month old healthy female with 14 month old healthy female with cough and nasal congestion x 2 cough and nasal congestion x 2 days, with tactile temperature days, with tactile temperature and 30 second episode of and 30 second episode of “shaking”?“shaking”?– PE?PE?

– Dx?Dx?

– Treatment?Treatment?

Seizures in childrenSeizures in children

Aged 0-9 years, prevalance is 4.4 Aged 0-9 years, prevalance is 4.4 cases per 1000, cases per 1000,

Aged10-19 years old 6.6 cases Aged10-19 years old 6.6 cases per 1000per 1000

Simple febrile convulsions occur Simple febrile convulsions occur in 3-4% of childrenin 3-4% of children

Febrile seizuresFebrile seizures

Antiepileptic drug therapy are Antiepileptic drug therapy are only used in pts with:only used in pts with:– Underlying neuro deficit (ie CP)Underlying neuro deficit (ie CP)

– Complex febrile seizureComplex febrile seizure

– Repeated seizure in the same febrile Repeated seizure in the same febrile illnessillness

– Onset under 6 mos of age or more Onset under 6 mos of age or more than 3 febrile seizures in 6 mos.than 3 febrile seizures in 6 mos.

Febrile seizures:Febrile seizures:

Aged 3 month to 5 yearsAged 3 month to 5 years Identify and treat causeIdentify and treat cause Acetaminophen, ibuprofen and tepid Acetaminophen, ibuprofen and tepid

water baths. water baths. Family history increases risk. Family history increases risk.

Case 2Case 2

19 year old healthy female breast 19 year old healthy female breast feeding a newborn has a tonic-feeding a newborn has a tonic-clonic seizureclonic seizure– PE? PE?

– Dx?Dx?

– treatment?treatment?

EclampsiaEclampsia

Pregnant women beyond 20 Pregnant women beyond 20 weeks’ gestation or up to 8 weeks weeks’ gestation or up to 8 weeks postpartum.postpartum.

SeizuresSeizures HypertensionHypertension Edema Edema Proteinuria Proteinuria

Eclampsia:Eclampsia:

Treatment: administration of Treatment: administration of magnesium sulfate 4 g IV magnesium sulfate 4 g IV

Followed by 1-2 mg/ hr, in Followed by 1-2 mg/ hr, in addition to antiepileptic medsaddition to antiepileptic meds

Case 3:Case 3:

50 year old male with tonic-clonic 50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on seizure lasting 2 minutes. Pt is on tegretol. tegretol. – PE?PE?

– Dx?Dx?

– Treatment?Treatment?

EpilepsyEpilepsy

Breakthrough seizures vs. Breakthrough seizures vs. noncompliance with medicationsnoncompliance with medications

Precipitating factorsPrecipitating factors– InfectionInfection

– Drug useDrug use

Treat or stabilize any injuries Treat or stabilize any injuries secondary to convulsionssecondary to convulsions

Epilepsy: managementEpilepsy: management

ABC’sABC’s Monitor VS and check blood Monitor VS and check blood

glucoseglucose Treat any injuriesTreat any injuries Transport to appropriate hospitalTransport to appropriate hospital IV and ALS monitorIV and ALS monitor

A/P: A/P: no longer seizing:no longer seizing:

Recovery positionRecovery position IVIV Blood glucoseBlood glucose Medication historyMedication history

A/P A/P is seizing stillis seizing still

Airway assessment (npa, suction, ETT Airway assessment (npa, suction, ETT prn)prn)

Protect patient from self injury Protect patient from self injury Pulse-ox, monitor, IV access, blood Pulse-ox, monitor, IV access, blood

glucoseglucose– Hypoglycemia is the most common Hypoglycemia is the most common

metabolic but can also be a result of metabolic but can also be a result of prolonged seizureprolonged seizure

– MedicationsMedications

Case 4: Case 4:

34 yo male with hx of alcoholism 34 yo male with hx of alcoholism found s/p seizure. found s/p seizure.

Pt is confused and combative. Pt is confused and combative. Vomiting. Vomiting.

Delerium Tremens Delerium Tremens (DT’s)(DT’s) Advanced stage of alcohol Advanced stage of alcohol

withdrawal withdrawal Altered mental status Altered mental status Generalized seizures Generalized seizures 6-48 hours after the last 6-48 hours after the last

drink. drink. Status epilepticusStatus epilepticus

Delerium Tremens Delerium Tremens (DT’s)(DT’s) TremorsTremors IrritabilityIrritability InsomniaInsomnia Nausea/vomitingNausea/vomiting

Hallucinations Hallucinations (auditory, visual, (auditory, visual, or olfactory)or olfactory)

ConfusionConfusion DelusionsDelusions Severe agitationSevere agitation

Treatment:Treatment: AirwayAirway

– Suction at handSuction at hand

– high risk for aspirationhigh risk for aspiration

– oxygenoxygen

IV accessIV access Immediate glucose testing or D50 Immediate glucose testing or D50

administrationadministration thiamine administration (100 mg IV)thiamine administration (100 mg IV) benzodiazepines in actively seizing pts. benzodiazepines in actively seizing pts.

Treatment of DT’s:Treatment of DT’s:

Do not use neuroleptics Do not use neuroleptics Administer adequate sedationAdminister adequate sedation

– To blunt agitation to and prevent the To blunt agitation to and prevent the exacerbation of hyperthermia, exacerbation of hyperthermia, acidosis, and rhabdomyolysis.acidosis, and rhabdomyolysis.

Delirium tremens: Delirium tremens:

Potentially fatal form of ethanol Potentially fatal form of ethanol withdrawal. withdrawal.

Symptoms may begin a few hours Symptoms may begin a few hours after the cessation of ethanol, but after the cessation of ethanol, but may not peak until 48-72 hours.may not peak until 48-72 hours.

Early recognition and therapy are Early recognition and therapy are necessary to prevent significant necessary to prevent significant morbidity and death. morbidity and death.

Case 5: Case 5:

22 yo female with 2 episodes of 22 yo female with 2 episodes of “shaking” in last 6 hours with active “shaking” in last 6 hours with active seizing for 15 minutes. seizing for 15 minutes. – PE?PE?

– Dx?Dx?

– Treatment?Treatment?

Status EpilepticusStatus Epilepticus

Continuous seizure activity lasting for at Continuous seizure activity lasting for at least 30 min, or two or more seizures least 30 min, or two or more seizures without intervening return to baselinewithout intervening return to baseline

Continuous seizure activity for >10min Continuous seizure activity for >10min should be treated as if in SE (most should be treated as if in SE (most seizures last 1-2 min)seizures last 1-2 min)

Impending SE if >3 tonic-clonic seizures Impending SE if >3 tonic-clonic seizures within 24hrswithin 24hrs

Generalized or PartialGeneralized or Partial

Status EpilepticusStatus Epilepticus

The longer the seizure continuesThe longer the seizure continues– The more difficult it is to stop The more difficult it is to stop

– The more likely permanent CNS The more likely permanent CNS injury will occurinjury will occur

TreatmentTreatment

Protect airway airway (NPA, OPA, Protect airway airway (NPA, OPA, ETT). If RSI is required, use short ETT). If RSI is required, use short acting paralytics.acting paralytics.

Obtain IV accessObtain IV access FS blood glucoseFS blood glucose Cardiac monitoringCardiac monitoring

First lineFirst line– Diazepam (Valium) IV/ET/IO/PRDiazepam (Valium) IV/ET/IO/PR

– Lorazepam (Ativan) IV/IMLorazepam (Ativan) IV/IM

– Midazolam (Versed) IV/IMMidazolam (Versed) IV/IM

Second lineSecond line– Phenytoin/fosphenytoin Phenytoin/fosphenytoin

– Phenobarbital (may cause respiratory and Phenobarbital (may cause respiratory and circulatory depression)circulatory depression)

Lastly induction of general anesthesia w. Lastly induction of general anesthesia w. cont. EEGcont. EEG– Infusions of midazolam, propofol, or Infusions of midazolam, propofol, or

pentobarbitalpentobarbital

– Inhaled isofluraneInhaled isoflurane

Questions??