Dilemmas in Acute Seizure Management Pearce J. Korb MD DISCLOSURES I have no relevant financial disclosures. There is some discussion of off label use of certain medications. These are all based on real and recent cases in the hospital. Contents Learning Objectives Appropriately recognize a firsttime seizure and discuss common differential diagnoses. Appraise the need for an antiseizure medication after a first time event and the reasoning for which medication to choose Apply current guidelines to the diagnostic workup of a first time seizure. Identify different forms of status epilepticus and treat it’s initial stages.
Transcript
Dilemmas in Acute Seizure Management
Pearce J. Korb MD
DISCLOSURES
I have no relevant financial disclosures. There is some discussion of off label use of certain medications.These are all based on real and recent cases in the hospital.
Contents
Learning
Objectiv
es
Appropriately recognize a first-‐time seizure and discuss common differential diagnoses.
Appraise the need for an anti-‐seizure medication after a first time event and the reasoning for which medication to choose
Apply current guidelines to the diagnostic workup of a first time seizure.
Identify different forms of status epilepticus and treat it’s initial stages.
List of dilemmas
1. Treating first seizure or not2. Which treatment3. Routine or continuous EEG or nothing4. Treating subclinical status5. Driving or not driving
Contents
Outlin
e
New Seizure
Differential Diagnosis
Evaluation
Treatments
Counseling
Status Epilepticus
Types
Recognition, Evaluation
Treatments
30,000 ft Hospitalist View
Hospital
AMS(status?)
Spells(seizure?)
Funny Movements(seizure?)
Case #1 – New Spell or SeizureA 55 year-‐old man is admitted to the hospital for a new onset spell that is described by EMS as a convulsion or “seizure”. He has fully recovered when you are admitting him.
Case #1 – New Spell or SeizureWhen you first get in the room, he is anxious and interrupts you asking:
What happened to me?
DILEMMA
CALL IT A SEIZURE OR SPELL?
Differential Diagnosis
Seizure • Epilepsy if 2 or more unprovoked
Syncope • Multiple causes, convulsive
Migraine • Migraine with aura, complicated migraine
Stroke/ TIA • Todd’s paralysis looks like stroke
Non-‐‑epileptic spells (psychogenic)• Can appear identical to epileptic seizures
Terminology/definitions
Seizure(s)• Abnormal electrical activity in the brain• Different symptoms or expression
Epilepsy• 2 or more unprovoked seizures• Or a tendency towards having seizures• Many different types
Provoked seizures
Alcohol
Traumatic brain injury
Hypoglycemia
Febrile seizures
Provoked – seizure triggered by an brain injury or insult that would have reasonably resulted in a seizure in any person AND if removed or avoided would likely lead to cessation of seizures.
Case #1 – New Spell or SeizureHe states he does not drink, does not have a history of epilepsy, is not taking any new medications.His blood sugar per EMS is normal.He asks you:Will this happen again?
Seizure recurrence
21% reoccurrence 2 years (Hauser ’82)
39% reoccurrence 5 years (Cleveland ’81)
71% reoccurrence 5 years (Elewes ’85)
Take home: Approximately 50% of those with new onset seizures will suffer reoccurrence
Case #1 – New Spell or Seizure
The ER provider asks youYou would like for him to get an anti-‐epileptic before he goes “upstairs” for admission? What do you need to know or what is important for that decision? (Free response on next slide)
DILEMMA
TO TREAT OR NOT TO TREAT?
Factors for Rx• Focal neuro exam• Lesion on imaging• Unprovoked• Abnormal EEG• Focal seizure• Long seizure
Factors against Rx• Normal neuro exam• Normal imaging• Provoked• Normal EEG• Generalized seizure• Short seizure
To Treat or Not to Treat
Diagnostic algorithm
Tests
Referral
Encounter
First History
Exam
Cardiologic
Holter monitorECG
Tilt table test
Neurologic
MRI brain EEG
Long-‐term EEG
monitoring
Electroencephalogram
EEG application
Scalp recordingElectro-‐potential differenceRoutine – 20-‐30 min
EEG tracing
Used to detect:SeizuresEpileptiform dischargesFocal slowing
Photos from lizarmy.com (top) and wikipedia.org (bottom)
Long-‐‑term video monitoring
Inpatient monitoring
Inpatient long-‐term video monitoringIncludes 24/7 EEG and videoEpilepsy Monitoring Unit (EMU)
Ambulatory EEG
The “take-‐home” testCan be used for 24-‐48 hoursNo videoMust keep journal
Photos from buffaloepilepsy.org (top) and hanix.net (bottom)
To Treat or Not to Treat
History• Long seizure?• Unprovoked?• Focal seizure?
Exam• Focal exam?
Imaging• Culprit lesion(s)?
EEG• Abnormal?
If the answer if yes to any of these questions, it could justify the use of anti-‐epileptic medications
Case #1 Continued
His seizure history is concerning for a focal seizure that lasting a long time. You decide to treat. What medication do you tell the ER provider to start? (respond on next slide)
Factors in Choosing an AEDBonus effects of common AEDs
Headache
Topiramate
Gabapentin
Mood Issues
Lamotrigine
Carbamazepine
Valproic acid
Neuro-‐pathic Pain
Gabapentin
Pregabalin
Carbamazepine
Obesity
Topiramate
Factors in Choosing an AED
Case #4 – New Spell or SeizureHe is admitted for observation. His EEG is consistent with epilepsy with epileptiform discharges. His MRI brain is normal. You started him on an AED. On discharge he has a lot of concern and you want to counsel him effectively.
• Calcium and Vitamin D supplements, bone density scansBone health
Driving and Epilepsy
Driving and Epilepsy
• Law varies by state• Colorado – No specific seizure freedom time but falls to national practice standard:– No driving until seizure free for 3 months (involving alteration of consciousness)
• Reporting vs. Non-‐reporting• Warning/ aura exemption
Seizure First Aid
• Keep Calm!• Don’t hold person down• Time the seizure• Clear the area, loosen ties, shirt• Turn on side• Do NOT put anything in the mouth
When to Call 911
• Seizures longer than 5 minutes• Turning blue, choking• A second seizure immediately after• Does not wake up after the seizure• Pregnant, diabetic, injured• Seizures in the water• First seizure ever, no prior history of epilepsy
Case #2 – Status Epilepticus65 year-‐old woman with history of stroke is admitted to your medicine service. She has a GTC and recovers fully but an hour later has another. She is given 2 mg of lorazepam but is still having tonic clonic movements. You arrive at bedside 5 minutes later.
Case #2 – Status Epilepticus
Does she meet criteria for status epilepticus and why or why not?a. No, her seizure has lasted < 30 minutesb. No, she fully recovered between the two
seizuresc. Yes, this is definitely status epilepticusd. a. and b.
Case #2 – Status EpilepticusOriginal definitionGCSE
> 30 minutes of recurrent epileptic seizures without full recovery of consciousness before next seizure begins
continuous clinical and/or electrical seizure activity, whether or not consciousness is impaired
Case #2 – Status Epilepticus
Revised working definition of GCSE (1999)
5 minutes of continuous seizures or
2 or more discrete seizures between which there is incomplete recovery of consciousness
Case #2 – Status EpilepticusYou are concerned about status epilepticus. She is still having convulsions. What is the next best step?
Case #2 – Status Epilepticus
Of the choices what is the next best step?a. Load with an anti-‐epileptic drugb. Give more lorazepam IVc. EEG statd. Administer propofol or other anesthetice. Intubate
Case #2 – Status Epilepticus
Don’t forget the basics0-‐5m
• ABC! (oral airway, O2, IV, EKG)
• Hx & Physical • Labs: AED levels,
chemistries, CBC, LFTs, tox screen, ABG
2-‐10m• Begin NS IVF
• 100 mg B1, Amp D50
Case #2 – Status Epilepticus
1. Hantus SMD. Epilepsy Emergencies. CONTINUUM: Lifelong Learning in Neurology.
2016;22(1, Epilepsy):173-‐190.
Case #2 – Status Epilepticus
1. Hantus SMD. Epilepsy Emergencies. CONTINUUM: Lifelong Learning in Neurology.
2016;22(1, Epilepsy):173-‐190.
Case #2 – Status Epilepticus
1. Hantus SMD. Epilepsy Emergencies. CONTINUUM: Lifelong Learning in Neurology.
Levetiracetam No interactions; few side effects; non-‐hepatic metabolism
No FDA label for status; case studies
1500 –2500 mgload
Ramael et al, 2006
Lacosamide No interactions; few side effects; non-‐hepatic metabolism
No FDA label for status; case studiesLittle experience
100-‐200 mg load over 30 min
Even more options for super refractory status
No controlled clinical trials, small patient series only
Topiramate
Ketamine
Inhaled anesthetics
Hypothermia
Magnesium
IV Steroids
ACTH
IVIG & Plasma exchange
TMS, VNS, DBS, ECT
Neurosurgery
Shorvon, S. and M . Ferlisi (2012).
Case #2You load her with 20 mg PE (phenytoin equivalents)/kg of IV fosphenytoin. Her seizure has not stopped by minute 10 (2 min after start of infusion) and you prepare for possible rapid sequence intubation (RSI) for airway protection in case you need to use sedation. The seizure stops as the infusion finishes.
Case #2Her daughter overhears you talking about intubation and possible ventilation. She is relieved the seizure is stopped but wants to know: • Why we would go so far as to put her on the ventilator?
• And what could have caused this?
Case #2 -‐‑ Mortality
Mortality Status Epilepticus
Mortality from SE can range from 3% to as high as 53% (GCSE)
• Cardiac/Resp. Arrest• Hepatic Failure• Renal Failure• Hypotension• Death
Case #2 -‐‑ Complications
Etiologies• Adults• Divided into acute and remote symptomatic or chronic/ progressive– Also unknown
• Acute causes are – More common and– associated with worse morbidity and mortality
Case #2
Take – home points:
• The working definition of status epilepticus is > 5 minutes (not 30)
• Associated with a high mortality that worsens the longer the status/seizure lasts
• Early treatment is essential and some of the steps can occur concurrently
Case #2
Status Epilepticus:
• A medical emergency!• Prolonged electrical seizure activity causes neuronal damage and memory deficits à harm
• EEG monitoring essential for subclinical seizures/ status epilepticus
• Longer the duration à worse outcomes• A predetermined Rx protocol is most effective
Case #3 – Altered Mental StatusA 42 year-‐old woman with a history of grand mal seizures now well controlled is admitted for kidney stones. She has a typical grand mal seizure (1-‐2 min) but is taking a while to wake up per her husband (3-‐4 hours ago).
Case #3 – Altered Mental StatusOn exam she is obtunded and not alerting with noxious stimuli. She has noisy breathing but is protecting her airway.
Case #3 – Altered Mental Status
Of the choices what is the next best step?a. Load with an anti-‐epileptic drugb. Give lorazepam (2mg) IVc. EEG statd. Administer propofol or other anesthetice. Intubate
Case #3 – Altered Mental Status
Non-‐convulsive status epilepticus
Convulsive vs. Non-‐‑convulsive
Status Epilepticus
Generalized Convulsive
Status (GCSE)
Non-‐convulsive (NCSE)
Subclinical Clinical
Generalized
Subtle Generalized
Status
Absence Status
Focal or Partial
Simple Partial Status (SPS)
Epilepsy PartialisContinua (EPC)
Complex Partial Status
Classification by EtiologyEtiology
Symptomatic “Known”
Acute
i.e. strokes, intoxication, encephalitis
Remote
i.e. post-‐traumatic, post-‐
stroke etc.
Progressive
i.e. brain tumor
Unknown
Non-‐‑Convulsive Status Epilepticus (NCSE) -‐‑ Subtypes
• No overt motor manifestations• Impaired consciousness/comaGeneralized
• Impaired consciousness• May have motor manifestations -‐ automatisms, focal clonic activity, dystonic posturing
• No impairment of consciousness• A.k.a /Epilepsy partialis continua (EPC)• Often focal motor manifestations, jerking of limb etc.
Simple Partial Status
Time of cEEG
0% 20% 40% 60% 80% 100%
> 24hrs
1hr-‐ 24hrs
> 30 mins
< 30 mins
20%
45%
65%
35%
Young et al, 1996
Time to first NCS
DILEMMA
TO TREAT OR NOT TO TREAT?
Mortality of NCS/NCSE
Treatment of NCSE
• CONTROVERSIAL • Considerations–What medications– Level of consciousness– Age– Type of NCSE– Etiology– EEG pattern– Prognosis
Benefits Risks
Case #3 -‐‑ Review
Take – home points:
• Non-‐convulsive status epilepticus can be harmful (although not as much as GCSE)
• More than one type of status epilepticus including subclinical
• EEG necessary for diagnosis• Treatment is controversial but initially can follow GCSE protocol (controversy is the domain of the ICU)
Other resources
Websites
Epilepsy Foundationwww.epilepsyfoundation.org
Epilepsy Foundation of Georgiawww.epilepsyga.org
Epilepsy.comwww.epilepsy.com
Seizure Trackerwww.seizuretracker.com
C.U.R.E. www.cureepilepsy.org
Tuberous Sclerosis Alliancewww.tsalliance.org
CDC – Epilepsywww.cdc.gov/epilepsy/
Twitter feeds
@epilepsyfdn
@epilepsyga
@cureepilepsy
@amepilespysoc
@epilepsycongres
@drpearcekorb
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