1. Seizures
A Engelbrecht

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

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

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

5. 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

6. 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

7. 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

8. 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

9. Buccal or nasal administration of midasolam

10. 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

11. 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

12. 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

13. Second drug: Phenytoin: I.V. Loading dose –
Manufacturer :10-15 mg/kg
Common use: 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

14. Purple glove syndrome (Phenytoin)

15. 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)

16. 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

17. 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

19. 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?

20. Case number 2:

21. 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%

22. 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

23. Neurocysticercosis

24. 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

25. 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)

26. 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

27. 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)

28. 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

30. ECG of case number 4

31. 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.

32. 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?

33. 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

34. 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?

35. 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

36. Case number 7
What is your differential diagnosis?

37. 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

38. Questions ?