Seizure: Difference between revisions

No edit summary
No edit summary
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##Posterior shoulder dislocation
##Posterior shoulder dislocation
##Focal deficit (Todd paralysis vs CVA)
##Focal deficit (Todd paralysis vs CVA)


==DDX==
==DDX==
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#Head CT
#Head CT
#LP (if SAH or meningitis/encephalitis is suspected)
#LP (if SAH or meningitis/encephalitis is suspected)
==Treatment==
==Treatment==
===Actively Seizing===
===Actively Seizing===
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**Do not place bite block
**Do not place bite block
**Ensure clear airway after seizure stops
**Ensure clear airway after seizure stops
*Most seizures stop on their own; meds only indicated for status
*Most seizures stop on their own; meds only indicated for status (sz >5min)


===History of Seizure===
===History of Seizure===
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===Status Epilepticus===
===Status Epilepticus===
*Continuous or intermittent seizures >5 min without recovery of consciousness
*Continuous or intermittent seizures >5 min without recovery of consciousness
*
*Consider secondary causes of seizure (e.g. hyponatremia, INH overdose, ecclampsia)
 
*Consider EEG to rule-out nonconvulsive status
 
*Consider prophylactic intubation
 
*Meds
 
**First-Line
 
***[Lorazepam 2mg IV (up to 0.1mg/kg) OR diazepam 5-10mg IV (up to 0.15mg/kg)] AND
 
***Phenytoin 20-30mg/kg at 50mg/min OR fosphenytoin 20-30mg/kg/PE at 150mg/min
 
****Phenytoin/fosphenytoin contraindicated in pts w/ 2nd or 3rd degree AV block
 
****Phenytoin may cause hypotension due to propylene glycol diluent
 
****Fosphenytoin may be given IM
Status  =  Sz >10min or intermittent without recovery >10min
**Refractory
 
***Valproic acid 20-40mg/kg at 5mg/kg/min OR
 
***Phenobarbital 20mg/kg at 50-75mg/min (be prepared to intubate) OR
# Ativan 2mg IVP (or Valium 5-10mg IVP)
***Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
# Ativan 2mg IVP
***Midazolam 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
# Dilantin (phenytoin) 1gm over 20min
***Ketamine 1.5mg/kg then 0.01-0.05mg/kg/hr
##(20mg/kg no faster than 50mg/min)
****Contraindicated in pts w/ intracranial masses
##contraindicatd in heart block
##monitor BP/rythm strip
##follow with dilantin 300mg PO QHS
# 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)
 
===Refractory Seizure===
#hyponatremia (infants, psych, etc) --> 3%NS
#isoniazide overdose --> pyridoxine
#ecclampsia?


Refractory Status Epilepticus, can also consider one of the  following:
===No IV===
#High Dose Phenytoin (30mg/kg)
#Midazolam IM 0.2mg/kg OR
#Valproic Acid
#Diazepam PR 0.5-1.0mg/kg (up to 20mg)
#Propofol


==Disposition==
==Disposition==
Negative workup:
#Typical seizure with known seizure history, normal w/u: discharge after reload
# Typical with known seizure history --> home after reload
#New onset seizure: Discharge with neuro follow up
# New onset --> home with neuro follow up (admit to Neuro at Harbor for expedited MRI)
#Status epilepticus: Admit ICU


==See Also==
==See Also==

Revision as of 03:52, 5 October 2011

Background

Types

  1. Generalized (consciousness always lost)
    1. Tonic-clonic
    2. Absence
    3. Other (myoclonic, tonic, clonic, atonic)
  2. Partial (focal)
    1. Simple partial (no alteration of consciousness)
    2. Complex partial (consciousness impaired)
    3. Partial seizures w/ secondary generalization

Precipitants (known seizure disorder)

  1. Medication noncompliance
  2. Sleep deprivation
  3. Infection
  4. Electrolyte disturbance
  5. ETOH or substance withdrawal
  6. Substance abuse

Causes (First-Time Seizure)

  1. Idiopathic
  2. Trauma (recent or remote)
  3. Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
  4. Structural CNS abnormalities
    1. Vascular lesion (aneurysm, AVM)
    2. Mass lesions (primary or metastatic neoplasms)
    3. Degenerative neurologic diseases
    4. Congenital brain abnormalities
  5. Infection (meningitis, encephalitis, abscess)
  6. Metabolic disturbances
    1. Hypo- or hyperglycemia
    2. Hypo- or hypernatremia
    3. Hyperosmolar states
    4. Uremia
    5. Hepatic failure
    6. Hypocalcemia, hypomagnesemia (rare)
  7. Toxins and drugs
    1. Cocaine, lidocaine
    2. Antidepressants
    3. Theophylline
    4. Alcohol withdrawal
    5. Drug withdrawal
  8. Eclampsia of pregnancy (may occur up to 8wks postpartum)
  9. Hypertensive encephalopathy
  10. Anoxic-ischemic injury (cardiac arrest, severe hypoxemia)

Diagnosis

  1. Check for:
    1. Head / C-spine injuries
    2. Tongue/mouth lacs
      1. Sides of tongue (true seizure) more often bitten than tip of tongue (pseudoseizure)
    3. Posterior shoulder dislocation
    4. Focal deficit (Todd paralysis vs CVA)

DDX

  1. Syncope
  2. Pseudoseizures
  3. Hyperventilation syndrome
  4. Migraine headache
  5. Movement disorders
  6. Narcolepsy/cataplexy

Diagnosis

  • Abrupt onset
  • Brief duratoin (typically <2min)
  • AMS
  • Purposeless activity
  • Unprovoked
  • Postictal state

Work-Up

Known Seizure Disorder

  1. Glucose
  2. Pregnancy test
  3. Anticonvulsant levels

New Diagnosis

  1. Glucose
  2. CBC
  3. Chemistry
  4. Pregnancy test
  5. Utox
  6. Head CT
  7. LP (if SAH or meningitis/encephalitis is suspected)

Treatment

Actively Seizing

  • Protect pt from injury
    • If possible place pt on side to reduce risk of aspiration
    • Do not place bite block
    • Ensure clear airway after seizure stops
  • Most seizures stop on their own; meds only indicated for status (sz >5min)

History of Seizure

First-Time Seizure

  • No treatment necessary if pt has:
    • Normal neuro exam
    • No acute or chronic medical comorbidities
    • Normal diagnostic testing (including normal imaging)
    • Normal mental status
  • Treatment generally indicated if seizure due to an identifiable neurologic condition

Status Epilepticus

  • Continuous or intermittent seizures >5 min without recovery of consciousness
  • Consider secondary causes of seizure (e.g. hyponatremia, INH overdose, ecclampsia)
  • Consider EEG to rule-out nonconvulsive status
  • Consider prophylactic intubation
  • Meds
    • First-Line
      • [Lorazepam 2mg IV (up to 0.1mg/kg) OR diazepam 5-10mg IV (up to 0.15mg/kg)] AND
      • Phenytoin 20-30mg/kg at 50mg/min OR fosphenytoin 20-30mg/kg/PE at 150mg/min
        • Phenytoin/fosphenytoin contraindicated in pts w/ 2nd or 3rd degree AV block
        • Phenytoin may cause hypotension due to propylene glycol diluent
        • Fosphenytoin may be given IM
    • Refractory
      • Valproic acid 20-40mg/kg at 5mg/kg/min OR
      • Phenobarbital 20mg/kg at 50-75mg/min (be prepared to intubate) OR
      • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
      • Midazolam 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
      • Ketamine 1.5mg/kg then 0.01-0.05mg/kg/hr
        • Contraindicated in pts w/ intracranial masses

No IV

  1. Midazolam IM 0.2mg/kg OR
  2. Diazepam PR 0.5-1.0mg/kg (up to 20mg)

Disposition

  1. Typical seizure with known seizure history, normal w/u: discharge after reload
  2. New onset seizure: Discharge with neuro follow up
  3. Status epilepticus: Admit ICU

See Also

Source

Tintinalli

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