Seizure Disorders
Patient education for seizure patient
- Avoid: driving, swimming, baths, operating heavy machinery, climbing ladders etc. until cleared by neurologist - Emphasize importance of compliance with meds; discuss with family
Etiologies of epilepsy
- Idiopathic: MC in 5-20 y/o - Genetic - Congenital abnormalities/perinatal injury - CNS vascular diseases: MC in > 60 y/o (strokes) - Degenerative CNS diseases: AD, dementia - Trauma - Tumors - Infectious disease
Atypical absence seizure
-form of generalized non-motor seizure Similar to typical absence seizures however pts: •Display more marked changes in muscle tone •Attacks may have a more gradual onset and termination than in typical absence seizures •Do not respond as well as those with typical absence seizures to meds
Evaluation of epilepsy in the ED
1. identify precipitating factors: may occur due to failure to take anticonvulsant 2. Physical exam: neuro, signs of trauma, heart, lung, repeat neuro if initially post-ictal 3. Tests: glucose, levels of anticonvulsants, CBC, BMP, UA, Tox, EKG, +/- CT head/neck and extremities if signs of trauma
Three goals of treatment of recurrent seizures
1•Controlling seizures 2•Avoiding treatment SE 3•Maintaining or restoring quality of life Start low and go slow
EEG for generalized non-motor seizures (Absence seizures)
3 Hz spike-and-wave discharge
What is the basic seizure classification based on?
3 key features 1.Where seizure begins in the brain 2.Level of awareness during a seizure 3.Other features of seizures
What can provoke a seizure?
Alcohol withdrawal, emotional stress, metabolic derangements (hypoglycemia), fever, drugs if epilepsy- bright/flashing lights, lack of sleep, drugs/caffeine, menstrual cycles
Causes of Psychogenic Nonepileptic Seizure (PNES)
Caused by: •Conversion disorder: Physical manifestations with no basis •Factitious disorder: attention seeking •Malingering: Faking it for gain of something or to get out of something
Treatment of epilepsy in the ED if anticonvulsant levels are therapeutic and patient has been compliant
Does seizure fall in usual pattern and frequency? Adjustment of medications may be needed, consult Neurologist
How long is drug therapy continued for seizures
Drug therapy is continued until pt seizure free for at least 3 years •Dose is reduced gradually over weeks to months •Drugs are withdrawn one at a time •Medications are re-started at usual dose if seizures recur
T/F: A partial seizure cannot become generalized
False: •A partial seizure may become generalized: •Focal to bilateral seizure sometimes begins so rapidly that its partial origin is not apparent clinically or on EEG
Etiology of status epilepticus in peds
Febrile status epilepticus
ADRs of Levetiracetam (KEppra)
Few, Most common SE are: Somnolence, dizziness, URI/flu like symptoms, asthenia(extreme fatigue) •Dosage adjustment in CKD, will be removed by HD •Does cross placenta and levels in fetus are comparable to maternal levels; can be used in pregnancy
What is a Aura
Focal seizures that effect enough of the brain to cause symptoms, but not enough to interfere with consciousness •Rarely last longer than seconds •Auras precede temporal lobe seizures in approximately 80% of cases •Abdominal and psychic are most common
Myoclonic seizure
Form of generalized non-motor seizure (absence seizure) •Consist of a single or multiple myoclonic jerks Non-motor because non-convulsive!!!
What is included in the Initial assessment of status epilepticus? What can be given at this time if the patient is hypoglycemic?
IVs, vitals, accu check, hx and exam, airway management or nasal O2, EKG, rectal temp, bladder catheter Blood work Imaging Give D50 IV if hypoglycemia; can consider glucose and thiamine IV
Two types of neuron channels
Ion channels and Ligand gated channels
Which AED is preferred in elderly and pregnant patients
Lamotrigine (Lamictal)
Epidemiology of focal impaired awareness (complex partial) seizures
MC in age >60
Etiology of complex partial seizures
Often unknown
Route of Phenytoin (Dilantin)
Oral and IV
Route of Levetiracetam (Keppra)
Oral and IV route
ADRs of topiramate (Topamax)
Same as most AEDs •Ataxia, impaired concentration, confusion, dizziness, fatigue, paresthesia, somnolence, depression, agitation and slowed speech
What is most important in prevention of SUDEP
Seizure control and patient monitoring (caregiver alert, nocturnal)
Seizing due to delirium tremens
Severe alcohol withdrawal - with symptoms such as shaking, confusion, and hallucinations (BUGS) •Withdrawal seizures can occur 6 hours to 4 days of alcohol cessation. •Highest risk is at >48 hours •These pt can go on to develop status epilepticus
DDX of partial seizures
TIA, Cardiac dysrhythmias
Where do most complex partial seizures originate?
Temporal lobe - represent underlying temporal lobe epilepsy
What explains why most seizures begin, and often stop, for no apparent reason during childhood
The dynamic state of synapses: •Synapses are in a state of flux during childhood and adolescence •They proliferate excessively and then they are reduced to adult levels
Phases of generalized motor seizure
Tonic and clonic and post-ictal
Management of febrile seizures
Treat the fever (Tylenol, Ibuprofen) and underlying illness
Role of lumbar puncture in evaluating seizures
Useful if suspect: •Possible meningitis or encephalitis •Obtunded pts •Suspected subarachnoid hemorrhage if imaging is negative
When are antiepileptic drugs started for seizures?
Usually after second seizure •IF after a single seizure the pt has a high potential to have another seizure (abnormality on MRI and EEG) then initiation of AED treatment is indicated
What is the etiology of generalized epilepsy
Usually idiopathic: However several genetic channelopathies have been identified
Therapy for status epilepticus
Within the first 5 min: •Ativan (Alternative Diazepam)- second dose if pt continues to seize •PLUS Fosphenytoin (Cerebyx)or Levitriacetam (Keppra) infusion- Should be started within 20 min of diagnosis being made; Prevents recurrence •Respiratory depression needs to be monitored •Provide supplemental O2 •Consider intubation
What is a seizure threshold?
describes that equilibrium between excitatory and inhibitory impulses. Certain drugs or situations lower that threshold.
Indications for Fosphenytoin (Cerebyx)
given IV •Used for status epilepticus and for short term seizure tx when oral meds can't be given
Simple febrile seizures
most common and generalized •Typically do not reoccur •Child loses consciousness with convulsions or rhythmic twitching of the arms or legs •Usually last 1-2 min, but may last up to 15 min •Child may be confused or sleepy but no focal deficits •Return to their baseline quickly
What should be done if the patient has a solitary seizure
no h/o seizure, ER eval and usually admit for observation •CT imaging and appropriate labs •r/o metabolic etiologies •EEG within 24 hours of seizure
Route of carbamazepine (Tegretol)
oral
Sudden unexpected death in epilepsy (SUDEP)
sudden and unexpected non-traumatic and non-drowning death in epilepsy •Pts usually found dead by family in am (usually unwitnessed) •Thought is that a seizure provokes SUDEP •In witnessed SUDEP pts have had transient apnea, bradycardia, or asystole followed recovery
Causes of seizures/epilepsy
•1/3rd due to genetic defects •1/4th due to structural lesions •The rest is unknown
Focal impaired awareness (Complex partial) seizure
•A complex partial seizure starts focally within the brain and causes impairment of consciousness. •They typically last 30 sec to 2 minutes •The patient is unresponsive and doesn't recall events
What is epilepsy
•A disorder defined as two or more unprovoked seizures
What is a focal (partial) seizure
•A seizure that arises from a neuronal network localized within one region of the brain or within a cerebral hemisphere •Partial seizures may become secondarily generalized, especially those of the frontal lobe
What is a seizure?
•A transient disturbance in cerebral function due to electrical hyper-excitable neuronal discharge in the brain - not the same as epilepsy!
Etiology of status epilepticus in adults
•Acute and long-term Structural brain injury or lesion •Infectious cause •Non compliance with seizure medications •Withdrawal syndromes •Overdose of medications that lower the seizure threshold
Status epilepticus disposition
•Admit to ICU, neuro consult, continuous EEG •CT/MRI imaging of brain among further work up to rule in or out causes
How is status epilepticus defined in actual clinical ED practice
•After 5 min of continuous seizure •OR 2 discrete seizures where there is no recovery from the ictal phase
Lacosamide (Vimpat) use as an AED
•Approved for monotherapy or adjunct therapy for partial seizure •Does not inhibit or induce CYP-450
Alcohol withdrawal seizures (DTs) treatment
•Benzodiazepines: Ativan prn if CIWA>8-10 •alt Diazepam IVE •If there are focal deficits investigate for structural abnormalities possibly related to trauma •Seizures are self limiting and do not require anticonvulsants long-term
Labs for new onset seizure disorder
•CBC with diff •Serum glucose •Liver and renal function tests •Serologic tests for syphilis in some •Tox screen •Serum prolactin level: drawn within 30 min of seizure •Obtaining AED drug levels if they have already been diagnosed with epilepsy and are on meds to control
CIWA scale for delirium tremens
•CIWA scales should be done every 4 hours by RN •Helps determine severity and treatment •<10 very mild withdrawal •10-15 mild withdrawal •16-20 modest withdrawal •>20 severe withdrawal
Imaging for status epilepticus
•CT non contrast of head •Consider C-spine if history is unknown •Chest XR
Infectious disease as a cause of epilepsy
•Can be a cause in any age group as a reversible cause of seizures •May occur in acute infection: Bacterial meningitis, Herpes encephalitis •Can occur chronic or long standing infections: Neurosyphilis •Seizure is a common sequela of brain abscess- Usually developing in the first year
Trauma as a cause of epilepsy
•Can occur in any age, but seen more in young adults •Epilepsy usually develop within 2 years of injury •If a seizure presents in the first week following injury this does not necessarily indicate that a seizure disorder has developed and may be related to brain injury
Which AEDs specifically cause increased risk of SJS/TEN in Asians
•Carbamazepine, oxcarbazepine, phenytoin, and lamotrigine
ADRs of Valproate (Depakote)
•Causes cognitive impairment of the fetus and should not be used in childbearing aged women •Valproate is worse than other AEDs •Do not need to renally adjust
What is status epilepticus (textbook definition)?
•Defined as either one below: 1. A single epileptic seizure lasting >30 minutes duration 2.OR a series of epileptic seizures however function is not regained between the ictal events over a 30 min period
ADRs of Pregabalin (Lyrica)
•Dosage adjustment in CKD, will be removed by HD •Major SE is dizziness, drowsiness, wt gain, difficulty concentrating and angioedema(rare)
ADRs with gabapentin (Neurontin)
•Dosage adjustment in CKD, will be removed by HD •Major side effect is somnolence: Medication is titrated slowly
Dose adjustment/ effectiveness of oxycarbazepine (Trileptal)
•Dose needs adjusted in stage IV of CKD •Can be effective, but may promote some types of seizures, so it is not as frequently used in US
ADRs of Carbamazepine (Tegretol)
•Dose-related adverse effects (neuro-toxicity) are: Dizziness, diplopia/blurry vision, nausea and ataxia •Hyponatremia may be more likely to occur in elderly •Asymptomatic LFT increase in 5-10% Rare adverse effects: •Aplastic anemia •Agranulocytosis •Thrombocytopenia •Hyponatremia especially in elderly •SJS and TEN
Significant side effects of AEDs
•Drowsiness •Somnolence •Ataxia •Confusion Increased risk of suicidality: Begins as early as 1 week with any AED •At risk pts need to be identified and pts/family counseled Steven's Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) Bone loss: •Increased risk for osteoporosis (worse for Dilantin)
What are Inhibitors of CYP450
•Drugs that decrease biotransformation rates results in higher plasma levels of a drug metabolized by CYP 450 •Sometimes they inhibit through competition for the same enzyme; other drugs inhibits the reactions of metabolism •So inhibitors slow down metabolism
What are Inducers of CYP450
•Drugs that increase biotransformation rates that results in lower plasma levels of a drug that is metabolized by CYP 450 •They speed up metabolism
What trick can be used to r/o real seizure if PNES is suspected
•ED trick used is ammonia inhalants also known as smelling salts •This brings pts out of their seizures quickly and also sometimes helps r/o a real seizure
Initial blood work for status epilepticus
•Electrolytes including Magnesium •Renal function •Tox screen •Glucose •LFT •CBC •AED levels •Pregnancy test if appropriate •CK •Lactic acid
Use of EEG in evaluation of new seizures
•Essential in the work up of epilepsy. •often nml in a patient not having an active seizure •Hyperventilation, sleep deprivation, photic stimulation may increase the likelihood of uncovering an abnormalities •Take 1-2 hours at minimum and are interpreted by a neurologist • classifies seizure and guides therapeutics •Continuous EEG monitoring may also be done
Treatment for generalized non-motor seizures (Absence seizures)
•Ethosuximide is first-line in most children •Dose should be titrated to maximum tolerated dose •If side affects are not tolerable or seizers are not well controlled once titrated management may be switched to valproate as monotherapy
ADRs to Lamotrigine
•Fewer CNS SE, most common is rash that can progress to SJS/TEN •Dose adjust for CKD •Significant pregnancy exposure, However no significant risk of major defect but increased risk of cleft lip/palate
Classification of seizures by behavior
•Focal motor Seizure: some type of movement occurs during the seizure event •Twitching, jerking or stiffening movements of a body part OR •Automatisms: Licking lips, rubbing hands, walking motions •Focal non-motor seizure: Changes in sensation, emotions, thinking or experiences •Generalized motor seizure: •Tonic-clonic - stiffening tonic and jerking (clonic). •Old terminology is a grand mal seizure •Generalized non-motor seizure: •Absence seizure •Brief changes in awareness like staring, may have automatic or repeated movements like lip smacking •Old terminology is a petit mal seizure
Post epileptic automatism
•Following a tonic-clonic seizure a pt may display abnormal behavior and subsequently have no memory or awareness of events.
Zosisamide (Zonegran) use as an AED
•For partial seizures •Not a CYP-450 inducer •Long half life,, good for non-compliant pt •Don't use if sulfa allergy
Drug interactions of AEDs *memorize :(
•GI meds: cimetidine, omeprazole, antacids •Anti-infectives: E-mycin, clarithromycin, fluconazole, antivirals •Oral contraceptives! •Warfarin •Psychiatric meds: St. John's wort, fluoxetine, sertraline, tricyclics, benzodiazepines
What age group most often experiences generalized seizures and what is the MCC
•Generalized seizures are rare in neonates and uncommon in infants •The most common cause in adults older than 60 is a brain lesions (tumor, stroke, AD)
Classification of seizures by where the seizure begins
•Generalized seizures: (previously primary generalized) •Starts on both sides of the brain at onset •Focal seizures: (previously partial seizures) •Starts on one part of the brain •Unknown onset: if the onset of a seizure is not known •This can be re-classified if the beginning of the seizure becomes clear •Focal to bilateral seizure: A seizure that starts in one side or part of the brain and spreads to both sides. (previously called secondary generalized seizure)
Classification of seizures by awareness during seizure
•Generalized seizures: Impaired consciousness •Focal (partial) aware: awareness remains intact •Even if the person is unable to talk or respond during a seizure •AKA simple partial •Focal (partial) impaired awareness: awareness is impaired or affected at any time during a seizure. •AKA complex partial seizure •Awareness unknown: unknown level of awareness
Risk factors for febrile seizures
•High fever •Types of infection-viral/OM •Recent immunization •FH of febrile seizure
What influences manifestation of focal (partial) seizures?
•Ictal manifestation of the seizure depend on the portion of the brain involved •Example: if a pt has a right side motor cortex seizure in the region that controls the hand they would have repeated extension/flexion movement of the left hand
Disposition of epilepsy in the ED
•If a precipitant is identified and labs are within normal range patient is often discharged home in the care of a family member AFTER they are back to their baseline and no longer post-ictal. Admission is considered if: • there is an identifiable cause on laboratory work up that requires hospitalization to fix. •They continue to have seizures that is outside of their normal pattern
When is 2 drug therapy used for seizures and what are the benefits/cons
•If pt is on maximum dosage and still having seizures a second drug is added and the first can be continued or withdrawn. •Two drug tx may decrease seizure but at the cost of SE and toxicity •Tx with >2 drugs is usually unhelpful
Use of pharmacologic treatment for Focal aware (simple partial) seizure
•If seizure does not become a secondary generalization, then drug treatment is not mandatory •No one drug is recommended for simple partial seizures, there are many options- Guided by epileptic specialist
Pregnancy with AEds
•Increased risk of birth defects •This should be a planned process with women of childbearing age •Given daily folic acid
When is seizure reoccurence more likely
•Initially failed to respond to meds •Have focal or multiple types of seizures •Have continuing EEG abnormalities
Clonic phase of generalized motor seizures
•Jerking of the body for 2-3 min •Periods of atonia alternate with episodes of violent flexion. •Atonic periods get progressively longer •Apnea continues •Tongue and lips may be bitten during this phase, urinary incontinence may occur at the end •Pt then lapses into a coma type state known as post-ictal
Physical exam for a first time seizure
•Lateralizing or focal signs in the postictal period suggest a focal origin •Oral trauma •Head to toe musculoskeletal exam
ADRs of Fosphenytoin and why it is preferred over phenytoin
•Major adverse effects are cardiac depression and hypotension that will be related to rate of infusion •Less of a problem than phenytoin Rate can be adjusted
Metabolism of Keppra
•Metabolism is independent of the CYP system •Because of this there less drug-drug interactions •Favored drug for the elderly
Drugs interactions of valproate (Depakote)
•Metabolized by cytochrome P450 system
Effect of phenytoin on CYP system
•Metabolized by liver and a potent broad-spectrum inducer of CYP system
How does Carbamazepine (Tegretol) effect CYP-450
•Metabolized through the liver by CYP-450- INDUCER •Induces it's own metabolism therefore drug levels need to be adjusted •Multiple drug interactions
Tumors as a cause of epilepsy
•More common in middle to later in life •The lesions may initially present with a seizure •Seizures are often partial (focal) •Most common in lesions of the frontal, parietal or temporal lobe •May present as status epilepticus •Tumors must be ruled out in any patient who presents with new onset of seizures
Manifestations of Focal aware (Simple partial) seizures
•Motor: Jerky, rhythmic movements that may remain restricted to one body segment or spread by "Jacksonian March" •Sensory: tingling, numbness, heat/cold, pain, phantom sensations •Psychic: Deja vu, hallucinations, illusions •Autonomic: abdominal (nausea, pain, hunger, and "epigastric rising" sensations) cardiac (arrhythmia), respiratory inhibition, pupillary changes, sweating •Consciousness is preserved and the patient can respond
Imaging for a first time seizure
•Neuroimaging is indicated for all pts with new onset seizures to rule out mass lesions. •Initially a CT without contrast would be done in the ED •Followed by MRI with and without contrast or in some cases a CT with and without contrast •CXR in certain pts
Idiopathic/constitutional epilepsy - age of onset
•No specific cause or other neurologic abnormality •Age of onset usually 5-20 years
Automatisms
•Non-purposeful stereotyped and repetitive behaviors that are inappropriate to the situation and pt does not recall MC: - Oral: lip smacking, chewing, swallowing - Manual: picking, fumbling hands Others: - Verbal: moaning, stereotyped speech - Complex motor: Bicycling motion with legs
Oxycarbazepine (Trileptal) Drug interactions and metabolism
•OXC does induce metabolism of OC, but no interactions with warfarin, CCB, e-mycins or Tagamet. •Metabolism occurs in liver, but only minimally affects the CYP-450 system
Risk of recurrence of solitary seizure and how this dictates treatment
•One tonic-clonic seizure, nml EEG, nml brain MRI and no evidence of focal onset: Low risk (15%), counseling to avoid provocation, no AED •1 seizure, abnormal MRI and evidence of an eliptiform focus on EEG: High risk- 80% •AED should be initiated •If a pt has 1 abnormality from the studies, MRI or EEG, their risk is 30-50% of seizure recurrence •AED treatment will not alter the natural history of the seizure disorder, if one is present •Goal of AED is to prevent a seizure during treatment period •The decision will be up to clinician (neurology) and patient
ADRs of Phenytoin (dilantin)
•Osteoporosis •Coarsening of facial features •Gingival hyperplasia, increased body hair •Loss of libido/hormone dysfunction •Vit K and folate deficiencies •Megaloblastic anemia •Teratogenic (cleft lip, congenital heart dz, slowed growth, mental deficiency)
Presentation of focal (partial) seizures
•Partial seizure may be less obvious to observers •They can cause auditory or olfactory sensations, paresthesia's or vertigo
Presentation of generalized non-motor seizures (Absence seizures)
•Presumed to be a genetic cause •Occur in childhood as frequent brief seizures that last a few seconds •Several a day can occur •Older children and adults frequently have longer duration absence seizures (several seconds to a minute) but are more likely to have fewer per day or less •If the patient is walking, they may continue to move or may stand still and stare
Considerations for patients on Carbamazepine (Tegretol)
•Protect from hot/humid conditions •Dosage adjustment for HD pts
Post-ictal phase of generalized motor seizure
•Pt gradually regains consciousness over minutes to hours. •During this transition, pt is confused •Pts complain of headache, fatigue and muscle aches that can last for many hours •Pooling saliva may cause stridor This can last 10 min to hours
Monitoring AEDs
•Pts may require and tolerate "toxic levels" of anti-epileptic medications without ill effects. •If level is subtherapeutic, the MCC is non-compliance Steady state drug concentrations should be measured: •After treatment is initiated •After dosage is changed or another drug is added •When seizures are poorly controlled
Presentation of focal impaired awareness (complex partial) seizures
•Pts typically do not respond to external stimuli, but they may make simple verbal responses, follow simple commands or continue to perform simple motor behaviors "Just because they do these things doesn't mean they are aware"
Pathophysiology of seizures
•Seizure occurs when the brain has a imbalance between excitatory and inhibitory impulses in a region that cause hyperexcitability. •A normal neuronal region can become chronically hyper-excitable, exciting other neurons and resulting in loss of inhibition
Two types of focal (partial) seizures
•Simple partial seizures: AKA focal aware seizures •Consciousness is preserved •Complex Partial Seizures: AKA focal impaired awareness •Impaired level of consciousness occurs with post-ictal manifestations
Generalized Seizure prodrome
•Some pts with generalized seizures suffer a prodrome hours before the seizure occurs in the form of HA, lethargy, irritability or other mood alterations •NOT auras •In most pts, seizures occur unpredictably without relation to posture or activity at the time.
Ddx of generalized seizure
•Syncope: •Occur with postural change, emotional stress, pain, instrumentation, or straining •Preceded by pallor sweating, nausea, malaise leading to LOC with flaccidity •Recovery occurs rapidly once pt is supine •No postictal HA or confusion •Brainstem Ischemia: •LOC precedes seizure or seizure is accompanied by other brainstem signs
Tonic phase of generalized motor seizure
•The entire body becomes rigid-flexion of the trunk and elbows followed by extension of the back, neck, arms, and legs. •Apnea occurs due to laryngospasm and pt falls to the ground •HR and BP both increase, change in sphincter pressure •Lasts 10-20 sec
What are generalized non-motor seizures (Absence seizures)
•There is impairment of consciousness, without loss of posture. •There can be subtle additional tonic-clonic, autonomic components or automatisms •Patient have no warning (aura) and there is no post-ictal period in absence seizures.
When do generalized non-motor seizures most often Begin? How do they progress?
•This type of seizure almost always begins in childhood (ages 4-8) or early teens •Children have intact cognition and intellect at time of diagnosis, however more formal testing may reveal mild deficits •Absence seizures become longer and less frequent as the child ages and may cease by age 20 •60-70% of children "outgrow" them
ADRs and drug interactions of Topiramate (Topamax)
•Topiramate can lead to wt loss through appetite suppression •Can cause renal calculi-hydrate well •Dose needs to be adjusted in CKD •Topiramate is induced by AEDs PHT and CBZ- Dose will need to be increased •Topiramate will induce the metabolisms of estrogens- Pt will need alternative method of contraception
medications that can lower the seizure threshold
•Tramadol •Cocaine •methamphetamines •Penicillin's •Fluoroquinolones (Cipro) •Lithium •TCAs •Pseudoephedrine
Risk factors for SUDEP
•Uncontrolled epilepsy- usually noncompliance to meds •>3 tonic-clonic sz/yr •Age <40, usually occurs between 18-40 •Polypharmacy •Nocturnal seizures •No AED
prognosis of status epilepticus and what causes mortality
•Up to a 20% mortality rate •This is considered an emergency •Prognosis relates to time between onset and start of effective medical treatment •Mortality is due to metabolic stress and repeated muscular convulsions that leads to: Hypoxia, Hyperthermia, Rhabdomyolysis, Lactic acidosis, Metabolic acidosis, Aspiration pneumonitis, Respiratory failure
Metabolic causes of provoked seizures
•Uremia: toxic CNS substances build up and can induce seizure if severe •Hypoglycemia or hyperglycemia: monitor diabetics closely •Withdrawal from ETOH, drug withdrawal, or ingestion may cause seizure
Presentation of psychogenic nonepileptic seizure (PNES)
•Usually no tonic phase and no injury to pt •Pt may shout or swear, pelvic thrusting •Often lasts longer than true seizures and there is not postictal phase •Pts may display goal directed behavior and preparation •Consider when pts continue to have seizures despite adequate therapy
status epilepticus
•a pt suffers further convulsions w/o recovery of consciousness between attacks. •Lasts longer than 30 minutes and is considered a medical emergency.
How are Ion channels activated and inhibited
•activated by changes in membrane potential •Depolarized by the inward flux of sodium and calcium •Inhibited by inward chloride and outward potassium flow that hyperpolarized the membrane.
How are Ligand-gated channels activated and inhibited
•activated by glutamate, inhibited by gamma-aminobutyric acid (GABA)
Complex febrile seizures
•focal •Can last more than 15 min or are recurrent within 24 hours •May have temporary weakness or arm or leg after seizure •Risk of recurrent is about 1/3rd and greatest in first year
Treatment of epilepsy in the ED if anticonvulsant levels are low/patient skipped dose
•give patient appropriate dose of their medication •A loading dose is often provided •Consult with their neurologist
Use of contraception with AED
•increased risk of failure with orals contraceptives •AEDs are teratogenic •Discuss other methods with pts
Alcohol use with AEDs
•infrequent use is probably ok (1-2 drink on occasion)
Epidemiology of febrile seizures
•occur in 3-5 % of children, and are most likely to occur between the ages of 3 months to 5 years •Peak incidence is at 18-24 months •Seizure threshold is lower in infants
Serial seizures
•pt suffers a second tonic-clonic seizure after regaining consciousness Full recovery before second seizure begins*