Jason Haag Intern Conference

Case 34 y.o. with h/o seizure disorder presents to ED with increased seizure frequency. He states he’s had 4 tonic-clonic seizures over the past 24 hours. He has a 6 year history of epilepsy treated with carbamazapine 400 mg po bid. He notes increased nausea, vomitting, and diarrhea over the last week which made him unable to take his meds. No fever, new medications, trauma or alcohol abuse

Case Physical Exam Mildly low BP (100/60) Lethargic, but able to follow commands Lateral tongue bites noted Neuro exam unremarkable Labs WBC 12, Na 132 Otherwise wnl

Case As you finish your exam the patient begins to have a tonic-clonic seizure lasting 2 minutes What do you do right now???? What are you thinking is causing the seizure??? Work up???

Epilepsy What is it? Tendency to have recurrent unprovoked seizures (2 or more) How common is it? Common, about 2.5 million people in US Common presentation complaints New seizure or increased frequency of seizures

Epilepsy Types of seizures Localization related seizures Partial or focal Start in one part of brain and may spread Simple or complex Simple = normal awareness Complex = impairied awareness May progress to generalized seizure Generalized seizures Involve both hemispheres of the brain at onset

Epilepsy Status Epilepticus 5 minutes of persistent seizures Or a series of recurrent seizures without a return to full consciousness between Does not have to be tonic-clonic seizure Nonconvulsant states can be in status i.e. absence, complex partial seizures

1 st Seizure Evaluation Seizure causes Head trauma Brain tumor CVA Encephalitis/Meningitis Hypoglycemia/nonketotic hyperglycemia (HONK) Hyponatremia/Hypernatremia Hypocalcemia, hypomagnesium Uremia Hyperthyroidism Anoxia Etoh/benzo withdrawal

1 st Seizure Evaluation Seizure imitators Syncope Psych d/o Sleep d/o (narcolepsy) Migraine TIAs

1 st Seizure Evaluation Work up Chemistry, thyroid function Prolactin (?) LP If concerned about infection Neuro imaging EEG Often normal or nondiagnostic

Acute Management of Seizures Goals Prevent aspiration/trauma Terminate seizure Prevent future seizures

Acute Management of Seizures What to do Place patient in lateral decubitus position with head elevated at 3o degrees (lessen risk of aspiration) Give oxygen Accucheck If low 1 amp D50 If h/o EtOH use give thiamine first Lorazepam.1 mg/kg total given in 2 mg increments May repeat every minute Can be given IV or IM, though better IV Can give rectally, but here we just don’t need to

Acute Management of Seizures Can load with IV phenytoin 15 mg/kg IV infusion rate 50 mg/min Watch for hypotension and arrythmias If allergic, can load with phenobarbital, valproate, levetiracetam

Status Epilepticus If seizures persist consider Intubation Lorazepam gtt.1 mg/kg/hr Can use propofol gtt Watch for complications of status epilepicus Lactic acidosis, hyperreflexia, electrolyte abnomalities, rhabdomyolysis and renal failure

Antiepileptic Drug Decision typically made by Neurologist Know common drugs and side effects MedicationMetabolismSeizure Efficacy Adverse Effects CarbamazepineHepaticPartialBone marrow suppresion, hepatitis, low Na PhenytoinHepaticPartialGum hyperplasia, rash, hirsutism, nystagmus ValproateHepaticGeneralizedWeight gain, alopecia, tremor, hepatitis, low platelets, pancreatitis LevetiracetamRenalGeneralizedBehavioral changes

Case What do you do right now???? Lorazepam IV +/- antiepletic What are you thinking is causing the seizure??? Electrolytes, thyroid function wnl Carbamazapine level subtherapeutic Work up??? Likely does not need imaging (h/o seizure d/o) or LP