Date post: | 01-Nov-2014 |
Category: |
Health & Medicine |
Upload: | student |
View: | 716 times |
Download: | 0 times |
1
The Management of the First Seizure
Dr Mohammed Tahir
٢/١٨/١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
2
Aims
• To have an understanding of the common causes of a first seizure presenting to the Emergency Department
• To have an understanding of the basic management of the first seizure
• To have some basic rules for seizure management
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
3
Definition of Seizure
An episode of abnormal neurological functioning caused by abnormal discharge of neurons!
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
4
Classification of Seizures
• Generalised - loss of consciousness• Partial - no loss of consciousness• Unclassified
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
5
Classification of Seizures
Generalised• Absence• Tonic Clonic• Myoclonic• Clonic• Tonic• Atonic
PartialSimple Partial•Motor•Sensory•Autonomic
Complex Partial•With psychic, cognitive or affective symptoms
•With automatism's
Partial seizures with secondary generalisation
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
6
Classification of Seizures by Etiology
• Acute Symptomatic seizures• Remote Symptomatic seizures• Idiopathic
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
7
Acute Symptomatic seizuresCNS infections•Meningitis•Encephalitis•Abscess
Vascular disease•CVA•Vasculitis
Trauma
Hypertensive
Eclampsia
Neoplasms•Benign•Malignant - Primary,
Secondary
Metabolic•Electrolyte disturbances•Hypoglycaemia•Hypoxia•Renal Failure
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
8
Acute Symptomatic seizures- Toxin Drugs
Tricyclic antidepressantsAntidepressantsTheophyllineWithdrawal - ETOH, benzo’sAnticholinergicsOrganophosphates
CocaineAmphetaminesLignocaineAnti -psychoticsAntihistaminesIsoniazid
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
9
Remote Symptomatic Seizures
• Previous head injury• Previous CVA• Congenital CNS disorders• Previous hypoxic injury• Previous CNS infections• Degenerative diseases
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
10
Incidence & Epidemiology
• 5% of the population have a seizure some time in their life
• Bimodal frequency• adult 1st generalised seizure accounts
for 1% ED visits
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
11
Causes of seizures presenting to Emergency Departments
Cause Sempere et al 1992 Henneman et al 1994
Idiopathic 27.6% 44.0%
Infarction 23.5% 11.0%
Cerebral Cystercercosis - 12.0%
ETOH 11.2% -
CNS infections 9.2% 10%
CNS tumour 8.2% 7.0%
Vascular Malformation 6.1% -
Trauma 4.1% 4.0%
Drug toxicity 3.1% -
Hyponaetraemia 2.0% 2.0%
Systemic Infection - 2.0%
Other 5.0% 9.0%
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
12
Causes of seizures by age
Cause Age < 45 years Age > 45 years
Idiopathic 45% 15.5%
Infarction 2.5% 37.9%
ETOH 15% 8.6%
CNS infections 17.5% 3.4%
CNS tumours 2.5% 12%
Vascular Malformation 7.5% 5.2%
Trauma 7.5% 1.7%
Drug toxicity 0% 5.2%
Other 2.5% 10.2%
Sempere et al 1992
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
13
Causes of seizures by age - acute symptomatic seizures
• 6/12 to 5 years -Febrile convulsions• Young adults -Trauma 26%
-Drug withdrawal 20%
• Elderly - CVA 44%
Annegers et al 1995
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
14
Presentation to the Emergency Department
Differentiated• Febrile convulsion• Idiopathic epilepsy • Acute symptomatic
seizures• Remote Symptomatic
seizures
Undifferentiated• Cardiac Arrhythmia's• Vasovagal Episode• Cardiac - Structural• Blood loss• Postural Hypotension• Sepsis• Psychogenic• etc
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
15
Presentation to the Emergency Department
• Has the patient had a seizure?• What kind of seizure was it?• Was there a focal component?• Was this the first seizure?• Is there a family history of seizure
disorder?• Why did the seizure occur?
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
16
Other Important History
• Systemic illness• drug use/abuse• pregnancy• mental retardation• head injury• unexplained bruises/tongue biting• nocturnal enuresis• precipitants
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
17
Management
• Historical documentation of the seizure• Physical examination• Investigations• Cessation of seizures• Observation• Disposal• Advice• Seizure Prophylaxis• Follow up/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of
help from Tony Holley)
18
Investigations
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
19
Rule
Always do a glucose on any one who is having a seizure or has had a seizure!
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
20
Scenario 1
• 17 year old girl• Post first witnessed tonic clonic seizure• Been out to a party the night before• Uncle has epilepsy• Now well, GCS 15, Vital signs normal• Neurological exam normal
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
21
Investigations
• Glucose• Sodium• Calcium• Consider urine and pregnancy test• CT [ MRI ] & EEG as outpatient
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
22
Post first seizure advice
• Management of a seizure at home• Safe activities• Driving• Who should know?• Have I got epilepsy?• Not life threatening• Exacerbating factors• Follow up
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
23
Seizure recurrence
• Most common within the first 6 months• More than 50% of those who have
recurrence will occur within 6 months• Rate varies from 36 -77%
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
24
Seizure recurrence increased if
•Symptomatic Seizure•History of epilepsy in a sibling•Todd’s paralysis•EEG abnormalities•2 seizures - 80-90%
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
25
RULE
Seizure prophylaxis for all first symptomatic
seizures
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
26
Scenario 2
• 50 yr old woman• Post tonic clonic seizure• Husband said twitching started in her R
arm, then progress to LOC.• History of recent headaches.• Now well, GCS 15, appears neurologically
intact• Vital signs normal/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of
help from Tony Holley)
27
RULE
ALWAYS LOOK IN THE FUNDI
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
28
RULE
First Focal Seizure = CT scan!!!!!!
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
29
Scenario 3
• 50 yr old woman• Post generalised seizure • Previously well, no seizures in the past• Recent headache for 24 hours, unwell & fever• Now GCS 13, Temp 39.8• Confused, unco-operative 30 minutes post
seizure• Moving all limbs.
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
30
Who to CT?
• Focal seizures• trauma• anticoagulants• alcoholics• immunosuppressed• fever,stiff neck,persistent headache• focal neurology
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
31
RULE
Do not LP a patient who has a decreased Glascow
coma score!!Treat first, CT & ask
questions later!!/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of
help from Tony Holley)
32
RULE
A GCS < 13 is a relative contraindication to LP
even after a normal CT!!
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
33
Scenario 4
• A 75 yr old man• Previous hypertension• Post tonic clonic seizure• Now GCS 15 but right arm weakness
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
34
RULE
Focal neurology = CT scan
Focal neurology does not = LP
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
35
Scenario 5
• 18 yr old man• Rugby injury with LOC, scalp laceration• Initially in ED GCS 15, vomited twice
and complaining of a headache• Has tonic clonic seizure in ED. Self
resolved• Now GCS 12 - 2 minutes post seizure
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
36
RULE
Trauma & Seizure
= CT scan!!
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
37
Status Epilepticus
• Continuous or repetitive seizures without time for recovery
• neuronal injury can occur in less than 30min
• may be subtle
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
38
RULE
• BEWARE THE INTER-ICTAL PATIENT
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
39
Treatment of Status Epilepticus
• All patients who still fitting on arrival to ED
• fitting for more than 10min• LONGER THE DELAY HARDER TO
CONTROL
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
40
0-5 minutes
• Confirm diagnosis• Oxygen• Airway & Breathing [ Consider ETT ]• Vital signs• IV access• Glucose check• Oximetry• Lab
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
41
5-10 minutes
• If hypoglycaemic treat• Adults 100 mg thiamine followed by 50
mls 50% glucose• Children 2 mls/kg 25%
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
42
10-20 minutes
•0.1 mg/kg lorazepam at 2mg/min up to 4 mg total
or•0.2 mg/kg diazepam at 5mg/min up to 20mg/min
Diazepam must be followed by a loading dose of phenytoin
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
43
Difficult access?
• IM midazolam 10mg• PR diazepam 0.5 mg/kg• PR lorazepam 0.1mg/kg
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
44
20+ minutes
• Load with phenytoin 20 mg/kg no faster than 50 mg/min in adults and 1mg/kg/min in children
• IV fluids must be N Saline
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
45
If Status continues
• 1. Additional phenytoin 5 mg/kg up to a total of 30 mg/kg
• 2. Midazolam load 0.2 mg/kg infusion • 3. Phenobarbitone 20mg/kg at max 100mg/min• 4. Proprofol load with 0.2mg/kg then infusion• Expect apnea• Intubation will be required - rapid sequence
induction with thiopentone and suxamethonium
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
48
Admission criteria for a first seizure
• Acute Symptomatic Seizure requiring ongoing treatment & investigation
• Febrile seizure where underlying cause needs treatment or fever does not settle
• Focal seizure
• Status epilepticus or prolonged seizure.
• Recurrent seizures• Social Situation
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
49
Conclusion
No one seizure is the sameThe clinician must always think of the underlying cause & investigate & treat
appropriately
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)
50
References
• Em Clinics N America Feb 1999 17;1• Emergency medicine reports Vol 18;14
1999• Neurology Nov 1999 S4• Lancet July 2000 Vol 356
/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)