Seizures A Engelbrecht

Content Introduction Principles of management Case studies 1 – 7 Conclusions Introduction: Seizure is a sign of an underlying condition Uncontrolled neuronal activity GABA inhibition

Principles of management First step is to confirm that a pulse is present Give case study

Principles of management Protect and maintaining the airway Patient turned on her side to protect against aspiration Trauma case: entire board tipped on side

Principles of management Protect patient from self-injury Establish IV access if possible Consider: Suction NP airway Pulse oximeter Oxygen Prepare for endotracheal intubation Prepare for endotracheal intubation in case anticonvulsant drugs fail

Principles of management ABC DEFG Hypoglycemia! Hypoglycemia the most common metabolic cause of seizure activity Prolonged seizure activity may also cause hypoglycemia The only treatment required for the patient may be administration of IV glucose

Principles of management Benzodiazepines Lorazepam (Ativan), diazepam (Valium), midazolam (Dormicum) If IV access cannot be achieved diazepam may be given rectally intraosseous NOT endotracheally Benzodiazepines are the optimal first-line agents for stopping seizure activity in patients of all ages All three are efficacious in terminating seizure activity Valium is acidic and causes chemical pneumonitis – Annals of EM

Benzodiazepines Rectal diazepam stops seizures in 70% Midazolam can be given IM Research: buccal midazolam works in children Buccal passes digestive system and first pass metabolism Absorbed through buccal mucosa

Buccal or nasal administration of midasolam

Lorazepam IV access: lorazepam is agent of choice Terminates higher percentage of seizures on first dose than diasepam Longer half-life: less recurrence of seizures Specifically recommended for alcohol withdrawal seizures, due to longer duration of action

Dosages of Benzo’s Drug Adult dosage Paediatric dosage Comment Diazepam 0.2 mg/kg IV at 2 mg/min up to 20 mg 0.2–0.5 mg/kg IV/IO/ET or 0.5–1.0 mg/kg PR up to 20 mg Monitor airway protection and respiratory drive Lorazepam 0.1 mg/kg IV at 1–2 mg/min to up to 10 mg 0.05–0.1 mg/kg IV Midazolam 0.1 mg/kg given at 1 mg/min up to 10 mg IV 0.15 mg/kg IV, then 2–10 mcg/kg/min 0.2 mg/kg IM 0.5 mg/kg buccal

Persistent seizures despite benzo administration Check Airway If airway is compromised Or sats below 90% Intubate If max dose benzo been reached (3X) Give second drug

Second drug: Phenytoin: I.V. Loading dose – Manufacturer :10-15 mg/kg Common use: 15-20 mg/kg Maximum rate: 50 mg/minute I.V. effects: Hypotension, tachycardia, cardiac arrhythmia, cardiovascular collapse (especially with rapid I.V. use), venous irritation and pain, thrombophlebitis Seizures in overdose! Fosphenytoin less side effects, but more expensive

Purple glove syndrome (Phenytoin)

Second drug: Valproate IV valproate is safe Rapid infusions ≤45 mg/kg over 5-10 minutes (1.5-6 mg/kg/minute) were generally well tolerated in clinical trials Onset of anticonvulsant effects are slower than phenytoin Adverse hematologic effects: thrombocytopenia (1% to 24%; dose related)

Persistent seizures Rapid sequence intubation Neuromuscular blocking agent is administered to reduce metabolic burden and hyperthermia General anesthetic doses of midazolam or propofol (TIVA) Anesthetic dosing midazolam is 0.2 to 0.3 mg/kg bolus, then 0.05 to 2.0 mg/kg/hr, and for propofol it is 2 to 4 mg/kg, then 1 to 15 mg/kg/hr Inotropic support Mechanical ventilation and critical care

Case number 1: A 45 year old male patient was admitted to the orthopaedic ward for a fracture of the left ankle after a minor fall GCS is 15/15 – no sign of a head injury 8 hours after admission the patient develops generalized tonic clonic seizures He has no history of epilepsy

Case number 1 How would you manage this case? A family member says that he is depressed and has lots of problems at home and at work. How would this influence your differential diagnosis? Which deficiencies do you expect and how would you correct it? What effect does ethanol have on GABA?

Case number 2:  

Case number 2: What are the characteristics of typical febrile seizures? Age 6m – 5j; tonic-clonic; <15minutes % of patients with typical febrile seizures with a positive LP? <1% % of patients with atypical febrile seizures with a positive LP? > 2.5%

Case number 2: The child visited Mosambique with his parents and returned 10 days ago The malaria smear and antigen is negative but you find neck stiffness on clinical examination What are the most common CNS infections that may cause seizures? Meningitis, encephalitis, cerebral abscess, cerebral parasitosis and CNS manifestations of HIV

Neurocysticercosis

Case number 3 A known epileptic present to your emergency department She is a 14 year old female She had intermittent seizures for the last 30 minutes She is on two anticonvulsant medications (unknown) She is brought in by friends During your initial management you insert an iv line and administer a dose of lorasepam

Case number 3 She continues to fit even after subsequent doses of lorasepam to the maximum reccomended dose. What is your next step? Are you allowed to give a second line therapy (fenitoin or valproate*) prior to obtaining plasma levels? Consolidated treatment program is lorasepam and half loading dose of 2nd line agent When level is back tailor dose of longer acting)

Case number 3 What is status epilepticus? 1hour? 30minutes? 5minutes? Body can withstand convultions for 1 hour max After 30 minutes Ca++ fluxes into neurons and cause cell damage Convultions are unlikely to terminate spontaneously if the persevered beyond 5 minutes Newest defenition is 5 minutes based on above

Case number 3 How long do you expect the post-ictal period to last? Usually no longer than 20 minutes The patient appears to have a L hemi-paresis after his last convultion. What is your differential diagnosis? Consider Todd’s Paralysis (exclusion)

Case number 4 A 16 year old female presents to your emergency department She had two episodes of seizures on her way to hospital in the back of an ambulance She recently failed her school exams and will have to repeat the school year She was found next to empty packets of medication prescribed to her mother Her bloodpressure is 60/40 and her pulserate is 140 per minute

ECG of case number 4

Case number 4 What is your ECG diagnosis and immediate management? Which drugs are associated with seizures? Cyclic antidepressants, antihistamines, cocaine, amphetamines, alcohol withdrawal, phenytoin, carbamazepine, plant toxins, insecticides, rodenticides, antimicrobials, cardiovascular drugs ect.

Case number 5: A 22 year old female present to the emergency department with tonic-clonic seizures She does not respond to first line therapy Her blood pressure is 220/160 What is your next step?

Case number 5 Her B-HCG is positive Abdominal examination reveals a palpable abdominal mass extending above the umbilicus Which anticonvulsant should be administered first? A series of systematic reviews reported magnesium sulfate was safer and more effective than phenytoin and diazepam

Case number 6: A known patient with a pancreatic malignancy present to your emergency department He suddenly develop an episode of seizures It is terminated by 2mg of iv lorasepam What could have caused his seizure? Which electrolyte abnormalities are most commonly associated with seizures?

Case number 7: An elderly resident of a Frail care home present to your emergency department after an episode of seizures He is known with Altzeimers disease and has a severely diminished short term memory He has a bruise to the side of the head and a low grade fever of 37.5 degrees Celsius He appears confused and has a RR of 25 per minute

Case number 7 What is your differential diagnosis?

Conclusions: Seizure is a sign of an underlying condition and not a diagnosis Try to determine the root cause ABC DEFG Benzo – second line – RSI - TIVA

Questions ?