Transcript Seizures for the Internist (intern curriculum 03.2015) FINALx

Seizures for the Internist
Stephanie K. Zia, MD
Assistant Professor
Clinical Internal Medicine & Pediatrics
Med/Peds Hospitalist
March 2015
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Identify important elements of a patient’s history
pertinent to a patient with seizures
Develop a differential diagnosis for a patient with
seizures
Risk-stratify the most likely etiology for a seizure in a
patient based on history and clinical presentation
Distinguish and provide initial management for lifethreatening seizures using A-B-C-D-E-F-G
Discuss appropriate management and work-up for a
patient with seizures
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Describe status epilepticus and its clinical
importance
Discuss a therapeutic approach to seizures in
pregnancy
Describe common side effects associated with antiepileptic therapy
You get called by the nurse to come assess
Mr. Cesar for twitching and nonresponsiveness. When you arrive to his
bedside, you note that he has twitching of
his arms and legs, and will not respond to
your voice.
Hint: go back to the basics….
Seizure interventions
• Reason for admission
• Past medical history
• Medications
• h/o seizure disorder
• h/o trauma
After ABC’s, take care of the 1, 2, 3’s…
▪ Step 1: H&P to rule out other conditions
▪ Syncope
▪ TIA
▪ Step 2: Once seizure confirmed…
▪ Determine acute symptomatic seizure vs
unprovoked seizure
▪ Treatment should always be directly at underlying
cause
A good history, physical, and neurologic exam are
key to diagnosis and may allow physicians to make
the diagnosis without additional diagnostic studies!
DDx seizures
Epilepsy
▪ Affects 2.2 million Americans and
65 million people worldwide
▪ 4th most common neurologic disorder
in US
▪ Increasing incidence in elderly
▪ Higher incidence in African American
and socially disadvantaged
populations
▪ Definition
▪ Presence of two or more
repeated unprovoked seizures
Types of Seizures
▪ Generalized Tonic-Clonic
▪ aka Grand Mal Seizure
▪ Absence
▪ aka Petite Mal Seizure
▪ No aura/postictal state
▪ Induced by hyperventilating
▪ EEG with characteristic 3-per-second spike &
wave pattern
Types of Seizures
▪ Simple Partial
▪ Focal seizures with preserved consciousness
▪ Small volume of cortex involved
▪ Complex Partial
▪ Focal seizures that impaired consciousness
▪ Typically originate from temporal or frontal
lobes
▪ Can secondarily generalize
Review
Symptoms of a Seizure (Ictal)
▪ Aura:
▪ subjective sensations
▪ Behavior:
▪ Mood or behavioral changes before the seizure
▪ Preictal Symptoms:
▪ described by patient or witnessed
▪ Vocal:
▪ Cry or gasp, slurring of words, garbled speech
Appendix 5
Neurology 2007;69:1996-2007
Symptoms of a Seizure (Ictal)
▪ Motor:
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Head or eye turning
Eye deviation
Posturing
Jerking (rhythmic)
Stiffening
Automatisms
(purposeless&
repetitive)
▪ Generalized or focal
movements
Appendix 5
▪ Respiration:
▪ Change in breathing
pattern
▪ Cessation of breathing
▪ Cyanosis
▪ Autonomic:
▪ Pupillary dilation
▪ Drooling
▪ Change in respiratory or
heart rate
▪ Incontinence
▪ Pallor
▪ Vomiting
Neurology 2007;69:1996-2007
Symptoms Following a Seizure (Post-Ictal)
Post-ictal states usually last
up to ~30 min – 1 hour
▪ Amnesia for events
▪ Confusion
▪ Lethargy
▪ Sleepiness
▪ Headaches and muscle aches
▪ Transient focal weakness
▪ Nausea or vomiting
▪ Biting of tongue
Appendix 5
Neurology 2007;69:1996-2007
Work-Up
Depends on suspected etiology
Partial Seizures commonly get more complete
work-up as an inpatient
AAN Practice Parameter Recommendations
Approach to First Unprovoked Seizure in Adults
EEG
▪ should be considered part of the routine
neurodiagnostic
evaluation of adults
presenting with an
apparent unprovoked
first seizure
▪ Has value in
determining risk for
seizure recurrence
Neurology 2007;69:1996-2007
AAN Practice Parameter Recommendations
Approach to First Unprovoked Seizure in Adults
Neuroimaging
▪ Brain imaging with CT or MRI should be considered
as part of the routine neurodiagnostic evaluation of
adults presenting with an apparent unprovoked first
seizure
Neurology 2007;69:1996-2007
Seizures and Imaging
▪ Important to rule out underlying symptomatic
cause (stroke, malignancy, ICH, mass)
▪ MRI with gadolinium superior to non-contrast CT
(except for SAH or hemorrhagic stroke)
▪ Role of functional imaging tests
(PET, photon emission CT, functional MRI)
▪ Use when planning for epilepsy surgery
Review 1
Review 2
AAN Practice Parameter Recommendations
Approach to First Unprovoked Seizure in Adults
Laboratory tests
▪ Laboratory tests, such as blood counts, blood
glucose, and electrolyte panels (particularly sodium),
may be helpful as determined by the specific clinical
circumstances based on the history, physical, and
neurologic examination
Neurology 2007;69:1996-2007
AAN Practice Parameter Recommendations
Approach to First Unprovoked Seizure in Adults
Laboratory tests (cont)
▪ Lumbar Puncture
▪ may be helpful in specific clinical circumstances in the
adult with an apparent unprovoked first seizure
▪ Toxicology screening
▪ May be helpful in specific clinical circumstances
Insufficient data to support or refute recommending
LP/toxicology screens for routine evaluation of adults
presenting with an apparent first unprovoked seizure
Neurology 2007;69:1996-2007
Treatment of Seizures
▪ Usually not started unless:
▪ patient has 2nd unprovoked seizure
▪ Increased risk factors
▪ EEG/structural abnormalities identified during
initial work-up
Treatment
Counsel About Triggers!
Medications
Illness
Stress
Menstruation Photic Stimulation
Sleep deprivation
Review
Treatment
▪ Selection of anti-epileptic drug (AED) based on
seizure type
▪ Generalized Seizures:
▪ Phenytoin, Phenobarbital, Valproic Acid,
Levetericetam
▪ Partial Seizures:
▪ Carbamazepine, Valproic Acid, Levetericetam,
Lamotrigine, Oxcarbazepime, Topiramate,
Zonisamide, etc
Review
Case 3
Leukopenia, thrompocytopenia
Stevens Johnson syndrome
Sleep disturbance
Gum hyperplasia, Stevens Johnson
Poor concentration
Metabolic acidosis
hepatotoxicity
Review
Common Side Effects of AEDs
Special Populations &
Areas of Consideration
Status Epilepticus (SE)
▪ Considered a neurologic emergency
▪ Definition has evolved
▪ Earliest definition—by duration—continuous seizure > 1 hr
▪ 30 minutes new “time period” given evidence of
pathologic changes and worsening prognosis associated
with seizures persisting 30 minutes
▪ >30* vs >5** minutes of continuous seizure activity or 2 or
more sequential seizures without full recovery of
consciousness between seizures
▪ “nutshell” definition—acute, prolonged epileptic crisis
▪ Different classifications
▪ EEG helpful for identifying subtypes
*MKSAP
**Epilepsy Foundation
Seizures and Pregnancy
▪ Risk for birth defects is doubled (2-3%4-6%)
from baseline with use of one AED
▪ 8% risk if on > polytherapy
▪ Treatment recommendation:
▪ Maintain on monotherapy if possible at lowest
dose possible
▪ Minimum folate intake 1-2 mg daily
▪ Goal of treatment: Control seizures
▪ Increased risk of placental abruption, early labor,
premature delivery with uncontrolled seizures
Slide
You get called by the nurse to come assess
Mr. Cesar for twitching and nonresponsiveness. When you arrive to his
bedside, you note that he has twitching of
his arms and legs, and will not respond to
your voice.
Mr. Cesar is a 55 year old male with a history of
diabetes mellitus who presents with a foot
ulcer and was admitted for IV antibiotics and
work-up to rule out osteomyelitis.
He was scheduled to have a pre-operative
nuclear study this afternoon and was made
NPO after breakfast, while awaiting his
procedure.
ABC’s
You get called by the nurse to come assess Mr.
Cesar for twitching and non-responsiveness.
When you arrive to his bedside, you note that
he has twitching of his arms and legs, and will
not respond to your voice.
Mr. Cesar is a 55 year old male who was
admitted for grave disability and placed on a
5150 hold by psychiatry.
The nurses on 2E report that he had been
exhibiting aggressive behavior earlier in the day
and was involved in an altercation with another
patient. Details are unclear, as the incident was
not witnessed.
ddx
On physical exam, he is found to have abrasions
on his face and some soft tissue swelling in his
temporal region.
Pupils are irregularly reactive to light
(2 mm OD, 5 mm OS).
You get called by the nurse to come assess Mr.
Cesar for twitching and non-responsiveness.
When you arrive to his bedside, you note that
he has twitching of his arms and legs, and will
not respond to your voice.
skip
Mr. Cesar is a 55 year old male with a longstanding history of primary generalized seizure
disorder. His last seizure was 3 months prior to
admission. He takes his Valproic Acid twice a day
and cannot remember the last time he missed a
dose.
He was admitted last night for nausea, vomiting,
and abdominal pain and was found to have
pancreatitis. He continues to have frequent emesis
and is currently NPO.
Treatment
• NPO except meds
• Give AED in IV form
• Seizure precautions
• Decision must be individualized!
• Seizure free x 2 years
• No epileptiform spikes on repeat EEG
• Normal MRI
• Must be at least 3-12 months seizure
free before driving privileges can be
reinstated (varies by state)
▪ A-B-C-D-E-F-G
▪ Crash cart
▪ Activate chain of command as warranted
▪ Basic PE
▪ Labs
▪ Interventions depending on clinical
presentation
▪ Medications
▪ Studies
▪ Consults
▪ Long-term considerations and counseling
▪ EEG for first unprovoked seizure
▪ Neuroimaging
▪ CT vs MRI
▪ Labs
▪ CBC, BMPglucose & Na
▪ additional studies as warranted based on
H&P, Neuro exam
▪ +/- LP
▪ +/- Utox
Time for Review…
What are the signs and symptoms of
the 4 main types of seizures?
Types of Seizures
Describe three categories in the
differential diagnosis of seizures
ddx
What imaging study is preferred after
a new onset seizure?
Imaging
Describe the sequence of
how to acutely manage
a patient with a seizure
ABC’s
What approaches can be taken with
intractable epilepsy?
Imaging
Name the situations in which CT is
preferred over MRI in the work-up of
seizures
What is status epilepticus?
>30* vs >5** minutes of continuous seizure
activity or 2 or more sequential seizures without
full recovery of consciousness between seizures
What factors contribute to the risk of
recurrence after an initial seizure?
Risk Factors
What metabolic derangements are
most commonly associated with
seizures?
What are the key elements of PE you
should perform in a patient with seizures?
What AEDs can be used in the
management of generalized seizures?
Treatment
What triggers must you counsel your
patients about?
Triggers
Match the associated side effect with AED
▪ Phenytoin (Dilantin)
▪ Valproic Acid
(Depakote)
▪ Phenobarbital
▪ Carbamazepine
(Tegretol)
▪ Ethosuxamide
▪ Lamotrigine (Lamictal)
▪ Topiramate (Topamax)
▪ Gabapentin
(Neurontin)
▪ Clonazepam
▪ Levetiracetam (Keppra)
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Pancreatitis
LFT abnormalities
Leukopenia, thrombocytopenia
Aggressive behavior
Stevens-Johnson syndrome (2)
Gum hyperplasia
Metabolic acidosis
Sleep disturbance
Exacerbates JME
Poor concentration
Sedation (3)
Trouble finding words
Side Effects
What are goals of epilepsy therapy in
pregnancy?
Seizures & pregnancy
The A-B-C’s of Seizure Intervention
▪ Airway
▪ Recovery position
▪ Breathing
▪ Assess & protect airway
▪ Circulation, Crash Cart
& head
▪ Dextrose
▪ Attach pt to a
▪ Electrolytes
cardiopulmonary
▪ First Line Abortive
monitor
Medication
Vital signs (get RN in
▪ Get Help If not yet done! room)
▪ Additional history
▪ Notify senior
resident/med consult, etc
Case 1
Review
Go Back
▪ Metabolic
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↓ Calcium
↓ Glucose
↑ or↓ Sodium
Hyperthyroidism
Dialysis disequilibrium
syndrome
▪ [↓ Magnesium (severe)]
▪ [Nonketotic hyperglycemia]
▪ Trauma
▪ Post-concussive
▪ Intracranial hemorrhage
▪ Space-Occupying Lesion
▪ Tumor/Mass
▪ Brain mets
▪ CNS lymphoma
▪ Toxoplasmosis
▪ AVM
▪ Infection
▪ Encephalitis +/- meningo
▪ Neurocysticercosis
▪ Brain abscess/perimeningeal
▪ Psych
▪ Pseudoseizures
▪ Epilepsy/Seizure Disorder ▪ Cardio-Respiratory
▪ ↑ ICP
▪ Hypoxia/anoxia
▪ Crytococcal meningitis
Differential Dx of Seizures
▪ Toxins/Medications
▪ CNS Stimulation
▪ Cocaine/Amphetamines
▪ Withdrawal
from agents
▪ ETOH
▪ Opioid
▪ Benzo
▪ GHB
▪ Decreased threshold
▪ Wellbutrin
▪ Haldol
▪ Tramadol
▪ Imipenem
Differential Dx of Seizures
Overview
Review
Case 2
Agents that Can Induce Seizures
Treatment
Risk Factors
▪ Meningoencephalitis
▪ History of childhood febrile seizures
▪ History of head trauma
▪ Family history of epilepsy
Review
Treatment
QUESTIONS?