Seizure: Difference between revisions

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==Background==
==Background==
SYNCOPE VS. SEIZURE
SYNCOPE VS. SEIZURE
 
#twitches vs more sig movements
twitches vs more sig movements
#quick return baseline vs postictal
 
#none vs retrograde amnesia
quick return baseline vs postictal
#none vs loss of continence
 
#tongue biting (tip) vs tongue biting (sides)
none vs retrograde amnesia
 
none vs loss of continence
 
tongue biting (tip) vs tongue biting (sides)
 


==Diagnosis==
==Diagnosis==
 
# Abrupt onset
 
# Brief duratoin (typically <1.5min)
SEIZURE
# AMS
 
# Purposeless activity
1) Abrupt onset
# Unprovoked
 
# Postictal state
2) Brief duratoin (typically <1.5min)
 
3) AMS
 
4) Purposeless activity
 
5) Unprovoked
 
6) Postictal state
 


==DDX==
==DDX==
 
# Syncope
 
# Hyperventilation
I. Syncope
# Breath-holding (children)
 
# Toxic/metabolic
II. Hyperventilation
## ETOH
 
## Hypoglycemia
III. Breath-holding (children)
## Tetanus
 
## Strychnine/camphos
IV. Toxic/metabolic
## Extrapyramidal reaction
 
# CNS event
    A. ETOH
## TIA
 
## Narcolepsy
    B. Hypoglycemia
## Carotid sinus hypersens
 
# Movement disorder
    C. Tetanus
## Hemiballismus
 
## Tic
    D. Strychnine/camphos
# Psych
 
## Pseudoseizure
    E. Extrapyramidal reaction
## Fugue
 
## Panic attack
V. CNS event
# Seizure
 
## Primary (epilepsy)
    A. TIA
### Subtheraputic level
 
## Secondary
    B. Narcolepsy
### Encephalitis
 
### Poisoning
    C. Carotid sinus hypersens
### Encephalopathy
 
### Metabolic disorder
VI. Movement disorder
### Pregnancy (eclampsia)
 
### CNS infection
    A. Hemiballismus
### CNS tumor
 
### Supratheraputic levels
    B. Tic
### Febrile
 
VII. Psych
 
    A. Pseudoseizure
 
    B. Fugue
 
    C. Panic attack
 
VIII. Seizure
 
    A. Primary (epilepsy)
 
          1. Subtheraputic level
 
    B. Secondary
 
          1. Encephalitis
 
          2. Poisonin
 
          3. Encephalopathy
 
          4. Metabolic disorder
 
          5. Pregnancy (eclampsia)
 
          6. CNS infection
 
          7. CNS tumor
 
          8. Supratheraputic levels
 
          9. Febrile
 


==Workup==
==Workup==
=== Typical with Known Sz Hx===
# Icon
# Glucose check
# Anticonvulsant levels
# +/- CBC & Chem 10
# +/- Utox


 
===New Onset===
A.  Typical with Known Sz Hx
# Icon/Glu check
 
# Head CT (*ED or short F/U if return nl)
1) Icon
# ECG
 
# CXR
2) Glucose check
# UA/Utox
 
# ETOH
3)  Anticonvulsant levels
# CBC, Chem 10, LFTs
 
# Anticonvulsant levels
4) +/- CBC & Chem 10
# DMV form/driving instructions
 
5)  +/- Utox
 
 
B.  New Onset
 
0) Icon/Glu check
 
1) Head CT (*ED or short F/U if return nl)
 
2) ECG
 
3) CXR
 
4) UA/Utox
 
5) ETOH
 
6) CBC, Chem 10, LFTs
 
7) Anticonvulsant levels
 
8) DMV form/driving instructions
 


-neuro-
-neuro-
 
# LP
9) LP
# HIV, ESR, RPR, ANA
 
# EEG
10) HIV, ESR, RPR, ANA
 
11) EEG
 
 
 
== ==
 


==Treatment==
==Treatment==
Status  =  Sz >10min or intermittent without recovery >10min
Status  =  Sz >10min or intermittent without recovery >10min


# O2/airway/protection
 
# Glu & Icon check (consider D50W)
1)  O2/airway/protection
# Ativan 2mg IVP (or Valium 5-10mg IVP)
 
# Ativan 2mg IVP
2)  Glu & Icon check (consider D50W)
# Dilantin (phenytoin) 1gm over 20min
 
##(20mg/kg no faster than 50mg/min)
3)  Ativan 2mg IVP (or Valium 5-10mg IVP)
##contraindicatd in heart block
 
##monitor BP/rythm strip
4)  Ativan 2mg IVP
##follow with dilantin 300mg PO QHS
 
# If continued, give Phenobarb 1gm over 20min
5)  Dilantin (phenytoin) 1gm over 20min
##(20mg/kg no faster than 50mg/min)
 
##prepare to intubate
    -(20mg/kg no faster than 50mg/min)
 
    -contraindicatd in heart block
 
    -monitor BP/rythm strip
 
    -follow with dilantin 300mg PO QHS
 
6)  If continued, give Phenobarb 1gm over 20min
 
    -(20mg/kg no faster than 50mg/min)
 
    -prepare to intubate
 
 
NO IV
 
-versed (midazolam) IM (0.2mg/kg)


-valium (diazepam) PR (0.5-1.0mg/kg up to 20mg)
===NO IV===
 
#versed (midazolam) IM (0.2mg/kg)
#valium (diazepam) PR (0.5-1.0mg/kg up to 20mg)


===Refractory Seizure===
===Refractory Seizure===
 
#hyponatremia (infants, psych, etc) --> 3%NS
 
#isoniazide overdose --> pyridoxine
-hyponatremia (infants, psych, etc) --> 3%NS
#ecclampsia?
 
-isoniazide overdose --> pyridoxine
 


Refractory Status Epilepticus, can also consider one of the  following:
Refractory Status Epilepticus, can also consider one of the  following:
 
#High Dose Phenytoin (30mg/kg)
-High Dose Phenytoin (30mg/kg)
#Valproic Acid
 
#Propofol
-Valproic Acid
 
-Propofol
 


==Disposition==
==Disposition==
Negative workup:
Negative workup:
 
# Typical with known seizure history --> home after reload
A. Typical with known seizure history --> home after reload
# New onset --> home with neuro follow up (admit to Neuro at Harbor for expedited MRI)
 
B. New onset --> home with neuro follow up (admit to Neuro at Harbor for expedited MRI)
 


==See Also==
==See Also==
Neuro: Seizure Levels and Reloading
Neuro: Seizure Levels and Reloading


Line 237: Line 115:


Peds: Febrile Seizure
Peds: Febrile Seizure


==Source==
==Source==
2/27/06 DONALDSON
2/27/06 DONALDSON


2/20/10 PANI
2/20/10 PANI


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 07:54, 28 March 2011

Background

SYNCOPE VS. SEIZURE

  1. twitches vs more sig movements
  2. quick return baseline vs postictal
  3. none vs retrograde amnesia
  4. none vs loss of continence
  5. tongue biting (tip) vs tongue biting (sides)

Diagnosis

  1. Abrupt onset
  2. Brief duratoin (typically <1.5min)
  3. AMS
  4. Purposeless activity
  5. Unprovoked
  6. Postictal state

DDX

  1. Syncope
  2. Hyperventilation
  3. Breath-holding (children)
  4. Toxic/metabolic
    1. ETOH
    2. Hypoglycemia
    3. Tetanus
    4. Strychnine/camphos
    5. Extrapyramidal reaction
  5. CNS event
    1. TIA
    2. Narcolepsy
    3. Carotid sinus hypersens
  6. Movement disorder
    1. Hemiballismus
    2. Tic
  7. Psych
    1. Pseudoseizure
    2. Fugue
    3. Panic attack
  8. Seizure
    1. Primary (epilepsy)
      1. Subtheraputic level
    2. Secondary
      1. Encephalitis
      2. Poisoning
      3. Encephalopathy
      4. Metabolic disorder
      5. Pregnancy (eclampsia)
      6. CNS infection
      7. CNS tumor
      8. Supratheraputic levels
      9. Febrile

Workup

Typical with Known Sz Hx

  1. Icon
  2. Glucose check
  3. Anticonvulsant levels
  4. +/- CBC & Chem 10
  5. +/- Utox

New Onset

  1. Icon/Glu check
  2. Head CT (*ED or short F/U if return nl)
  3. ECG
  4. CXR
  5. UA/Utox
  6. ETOH
  7. CBC, Chem 10, LFTs
  8. Anticonvulsant levels
  9. DMV form/driving instructions

-neuro-

  1. LP
  2. HIV, ESR, RPR, ANA
  3. EEG

Treatment

Status = Sz >10min or intermittent without recovery >10min

  1. O2/airway/protection
  2. Glu & Icon check (consider D50W)
  3. Ativan 2mg IVP (or Valium 5-10mg IVP)
  4. Ativan 2mg IVP
  5. Dilantin (phenytoin) 1gm over 20min
    1. (20mg/kg no faster than 50mg/min)
    2. contraindicatd in heart block
    3. monitor BP/rythm strip
    4. follow with dilantin 300mg PO QHS
  6. If continued, give Phenobarb 1gm over 20min
    1. (20mg/kg no faster than 50mg/min)
    2. prepare to intubate

NO IV

  1. versed (midazolam) IM (0.2mg/kg)
  2. valium (diazepam) PR (0.5-1.0mg/kg up to 20mg)

Refractory Seizure

  1. hyponatremia (infants, psych, etc) --> 3%NS
  2. isoniazide overdose --> pyridoxine
  3. ecclampsia?

Refractory Status Epilepticus, can also consider one of the following:

  1. High Dose Phenytoin (30mg/kg)
  2. Valproic Acid
  3. Propofol

Disposition

Negative workup:

  1. Typical with known seizure history --> home after reload
  2. New onset --> home with neuro follow up (admit to Neuro at Harbor for expedited MRI)

See Also

Neuro: Seizure Levels and Reloading

Peds: Seizure (Peds)

Peds: Febrile Seizure

Source

2/27/06 DONALDSON

2/20/10 PANI

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