Dr. Zolfaghari Assistant Professor of Emergency Medicine Dr. Farahmand Rad Assistant Professor of Emergency Medicine

 Seizure: episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons.  Epilepsy: clinical condition in which an individual is subject to recurrent seizures.

 Caused by a nearly simultaneous activation of the entire cerebral cortex

 Due to electrical discharges in a localized structural lesion of the brain.  Affects whatever physical or mental activity that area controls.

 Generalized seizures (consciousness always lost) o Tonic colonic seizures (grand mal) o Absence seizures (petit mal) o Myoclonic seizure o Atonic seizures

 Partial (focal) seizures: o Simple partial no alteration of consciousness o Complex partial consciousness impaired o Partial seizures (simple or complex) with secondary generalization

 Trauma (recent or remote)  Intracranial hemorrhage  Eclampsia  Hypertensive encephalopathy  Structural abnormalities  Vascular lesion (aneurysm, AV malformation)  Mass lesion  Degenerative disease  Congenital abnormalities

 Toxins and drugs  Anoxic brain injury  Metabolic disturbances  Hypo or hyperglycemia  Hypo or hypernatremia  Hyperosmolar states  Uremia  Hepatic failure  Hypocalcemia, hypomagnesemia (rare)

 Abrupt loss of consciousness and loss of postural tone  May then become rigid  With extension of the trunk and extremities  Apnea  Cyanosis  Urinary incontinence

 As the tonic (rigid) phase subsides, clonic (symmetric rhythmic) jerking of the trunk and extremities develop  Episode lasts from seconds  Consciousness returns gradually  Postictal confusion may persist for several hours

 Continuous seizure activity lasting for at least 5 min  Two or more seizures without intervening return to baseline  Non-convulsive status epilepticus is associated with minimal or imperceptible convulsive activity and is confirmed by EEG

 Careful history  Important historical information:  Include rapidity of onset,  Presence of a preceding aura  Progression of motor activity (local or generalized)  Incontinence.

 Duration of the episode and whether there was postictal confusion  Contributing factors:  Sleep deprivation  Alcohol withdrawal  Infection  Use or cessation of other drugs

 History of head trauma  Headache  Pregnancy or recent delivery  History of metabolic derangements or hypoxia  Systemic ingestion or withdrawal and alcohol use.

 Injuries resulting from the seizure  such as fractures, sprains, posterior shoulder dislocation, tongue lacerations, and aspiration.  Localized neurological deficits  Todd’s paralysis

 Syncope  Hyperventilation syndrome  Complex migraine  Movement disorders  Narcolepsy  Pseudo-seizures

1) Airway:  Oxygen  Pulse oximetry  Endotracheal intubation  for prolonged seizure  If RSI is performed, a short acting paralytic agent should be used so that ongoing seizure activity can be observed

2) Breathing:  Suction  Airway adjuncts 3) Circulation: IV access  IV glucose if confirmed hypoglycemia

 Continuous seizure activity lasting for at least 5 min, or two or more seizures without intervening return to baseline  Continuous seizure activity for >5min should be treated (most seizures last 1-2 min)  Impending SE if >3 tonic - colonic seizures within 24hrs generalized or partial

 The longer the seizure continues  The more difficult it is to stop  The more likely permanent CNS injury will occur

 Protect airway (NPA, OPA, ETT). If RSI is required, use short acting paralytics.  Obtain IV access  Blood glucose  Cardiac monitoring

 Antiepileptic drug therapy are only used in pts with:  Underlying neuro deficit (ie CP)  Complex febrile seizure  Repeated seizure in the same febrile illness  Onset under 6 mos of age or more than 3 febrile seizures in 6 mos.

 Aged 6 month to 5 years  Identify and treat cause  Acetaminophen, ibuprofen and tepid water baths.  Family history increases risk.

 Pregnant women beyond 20 weeks’ gestation or up to 8 weeks postpartum.  Seizures  Hypertension  Edema  Proteinuria

 Treatment: administration of magnesium sulfate 4 g IV  Followed by 1-2 mg/ hr, in addition to antiepileptic meds

 Breakthrough seizures vs. noncompliance with medications  Precipitating factors  Infection  Drug use  Treat or stabilize any injuries secondary to convulsions

 ABC’s  Monitor VS and check blood glucose  Treat any injuries  Transport to appropriate hospital  IV and monitoring

 Recovery position  IV  Blood glucose  Medication history

 Airway assessment (PA, suction)  Protect patient from self injury  Pulse-ox, monitor, IV access, blood glucose  Hypoglycemia is the most common metabolic but can also be a result of prolonged seizure  Medications

 Advanced stage of alcohol withdrawal  Altered mental status  Generalized seizures  6-48 hours after the last drink.  Status epilepticus

 Tremors  Irritability  Insomnia  Nausea/vomiting  Hallucinations (auditory, visual, or olfactory)  Confusion  Delusions  Severe agitation

 Airway  Suction  high risk for aspiration  oxygen  IV access  Immediate glucose testing or D50 administration  thiamine administration (100 mg IV)  benzodiazepines in actively seizing pts.

 Do not use neuroleptics  Administer adequate sedation  To blunt agitation to and prevent the exacerbation of hyperthermia, acidosis, and rhabdomyolysis.

 Potentially fatal form of ethanol withdrawal.  Symptoms may begin a few hours after the cessation of ethanol, but may not peak until hours.  Early recognition and therapy are necessary to prevent significant morbidity and death.

 14 month old healthy female with cough and nasal congestion x 2 days, with tactile temperature and 30 second episode of “shaking”?  PE?  Dx?  Treatment?

 19 year old healthy female breast feeding a newborn has a tonic-clonic seizure  PE?  Dx?  treatment?

 50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on tegretol.  PE?  Dx?  Treatment?

 34 yo male with hx of alcoholism found s/p seizure.  Pt is confused and combative.  Vomiting.

 22 yo female with 2 episodes of “shaking” in last 6 hours with active seizing for 15 minutes.  PE?  Dx?  Treatment?

Questions??