Seizure, April 23rd

As mentioned with syncope: consciousness  requires organized electrical acvitiy, glucose, oxygen, and blood pressure (and a conduit to get it there).

So when one here’s the word seizure – form nurse, patient, family member, always clarify what they mean.

Some classic questions you will and should have

Any witnesses? How did it start?

The last thing before they lost consciousness (if they did)

The first thing when they woke up

Déjà vu, nausea, dizziness odd smells (mesial temporal lobe seizure)

Bowel, bladder incontinence, tongue biting.

FYI: often times when a patient has had a seizure, juniors will start off by saying “seizure” and then mentioning that they did NOT have bowel or bladder incontinence. Always start by going over the pertinent positives FOR seizure, especially if that’s the story you are trying to sell.

So what do we do for a patient that is actively seizing in front of us?

ABCs, are they protecting their away?  Do they need to be sedated and intubated?

Ativan IV/IM, midaz IV/IM or diazepam per rectum are options.

Ativan 2 mg IV or IM is a standard starting dose and this should be repeated after 1-2 minutes, it has a quick onset.

An approach to seizure is actually similar to that of delirium!

DIMS! (drugs, infection, metabolic, structural)

Drugs – etoh withdrawal, TCAs, certain antibiotics lower seizure threshold, tox screen

Infection – mengintis and encephalitis are most feared ones,  blood cultures, +/- CT head, LP. Also note, an infection precipate a seizure in a previously controlled patients with epilepsy

Metabolic – hypoglycaemia, hyponatremia, cerebral edema from liver failure, hypocalcemia,

Structural – new stroke, brain mass, AV malformation, lowe threshold for CT head, and potentially MRI and EEG to localize an area.

Blood work to be done when a patient comes in would consist of BG (to look for hypoglycaemia) CBC (very high WBC in meningitis), lytes (hyponatremia, hypocalcemia), BUN/cre, drug levels if they are on seizure medications. Lactic acid if a patient came in with suspected seizure as it is often very high. CK to look for rhabdo

So now you’ve confirmed a seizure based on presentation, response to Ativan, consider the causes as above with DIMS. Consider stroke or bleed in people over 65 with new onset seizure, ask about family history in a child, look for neurocutaneous disease tuberous sclerosis, sturge weber.

O/E make sure patient is maintaining airway, often patients are drowsy in the post icatal period (or the benzos have kicked in). you can still examine pupils for asymmetry, can they localize with sternal rub? Response to nail bed pressure? Rigidity, reflexes? We may see a todd’s paralysis which is an are of brain that needs to wake up post seizure.

In someone with previously controlled seizure, always try to figure out what tipped them over this time, not JUST about controlling it. Similar to previously controlled afib, are they septic now, new heart failure, dehydrated, etc. So not JUST to give beta blockers and call it a day.

Driving: single unrpvodked seizure, normal eeg AND mri, NO REStricitons, usually no meds

So after you’ve controlled the new onset seizure, you then will consider loading them with phenytoin.

Phenytoin – 15 mg/kg, for a 70 kg man 1 g. Run it 50 mg /min, if faster lower BP (in fact if its low slow it down). Put them on a monitor, be careful of patients with cardiac arrhythmias, give with normal saline, it will precipitate if given with dextrose (nurse should have protocol for this). Nystagmus on lateral gaze, good sign they are taking the meds! Gait ataxia and lethargy signs of toxicity. Hirsutism, gingival hyperplasia, Metabolized by liver so not usually a problem in renal failure, megaloblastic anemia, osteomalacia, drug induced lupus. Be aware of hypotension from giving the med too fast, an expected response, just slow down the rate.

Carbamazepine:  600-1200 mg/day leucopenia, thrombocytopenia, hyponatremia, hepatic dysfunction

Dose of phenytoin is 300 to 400 mg /day. Drug level 10-20 albumin can alter it. Check level to see what level they are controlled at.

Status epilepticus, we used to say 30 minutes now we say 5 min. High mortality, adding agents, step up with valproic acid, then propofol (intubate) pressors, hook them up and look for burst suppression.

Risk of recurrence? structural brain, EEG with definite epileptiform pattern, history of prior brain insult, status epilepticus in first seizure

Discontinuing meds American Academy of Neurology suggest patients who were seizure free 2-5 with a single type of partial or generalized seizure, normal neuro exam, normal EEG. 60-70% chance of success.

http://m.neurology.org/content/84/16/1705.full some updated guidelins from American neurology fresh off the press!