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Flashcards in Seizures Deck (29):
1

Define:
-seizure
-epilepsy
-convulsion

Seizure: sudden excessive disorderly discharge of neuronal activity in the brain

epilepsy: recurrent unprovoked seizures


convulsion: body muscles contract and relax rapidly and repeatedly, uncontrolled shaking of the body

2

Causes of Epilepsy?
Prevalence?

Seizures beginning after age 20 are usually d/t what?

-genetic mutations
-hypersensitive neurons
-epileptogenic neurons (fire more intensely, more often, and with greater amplitude)

Prevalence:
-highest in children, 2-5yrs and at puberty. *usually idiopathic or primary generalized epilepsy
-pts older than 50yo

Seizures beginning after age 20 are usually due to a focal process or metabolic derangement.

3

What are the most common causes of seizures:
-infancy childhood
-adolescence
-young adult
-middle age
-late life
-other

infancey/childhood: fever, trauma, hereditary metabolic, injury, infections

adolescence: idiopathic

young adult: trauma, alcohol, drugs

middle age: cancer, alcohol, vascular dz (stroke)

late life: vascular dz, cancer, degenerative brain disorders

Other: sleep deprivation, fever, withdrawl

4

What is the difference between provoked and unprovoked seizures?

unprovoked seizures occur in the setting of persistent brain pathology whereas provoked are triggered by factors in an otherwise healthy brain.

5

exacerbations of seizure disorders are most commonly due to?

Mortality of epilepsy patients is d/t?

-medication noncompliance
-alcohol use
-menses


Mortality d/t underlying cause of epilepsy or sudden unexpected death of epilepsy (SUDEP; sudden, unexpected, nontraumatic, nondrowning)

6

Describe the Phases of seizures:
-prodrome
-aura
-middle
-ending

prodrome: feeling, sensation or changes in behaviors hours or days before seizure..deja vu, smell, sounds, taste, fear, HA, nausea

aura: 1st sx of a seizure and considered part of the seizure

Middle: "ictal phase"
-sx: loss of awareness, confusion, distracted/daydreaming, difficulty talking, unable to swallow, repeated blinking of the eyes, lip smacking or chewing movements.

Endin: "postictal phase"
Sx: slow to respond, sleepy, confused, injuries, HA, nausea

7

What are the types and Describe the difference between focal and generalized seizures?

-focal: limited to one cerebral hemisphere
--focal seizure without impairment of consciousness
--focal seizure with impairment of consciousness

Generalized: involves the cerebral cortex of both sides of the brain
--absence (petit mal)
--myclonic
--clonic, tonic, atonic
--tonic-clonic (grand mal)

8

Focal seizures w/o impaired consciousness can be categorized into what groups?

-Motor (jacksonian march; jerking stays on one side of the body, weakness, affected speech, coordination of actions)

-sensory: changes sense of smell and taste, clicking, ringing, pins/needles, floating in space, illusions, hearing voices

-autonomic: chest discomfort, changes in heart rate and breathing

-psychic: garbled speech, written language is off, trouble word finding

9

Features of focal seizure w/o impaired consciousness

-prodrome/aura
-Todds paralysis (temporary, unilateral, 30min-36hrs)
-can progress to focal seiz w/ impaired consciousness to tonic clonic seizure

10

Focal seizure WITH impaired consciousness
-what?
-arise from which lobe?
-sx
-duration
-

what: produce unresponsiveness

arise from the temporal lobe

duration: 30seconds to 2 minutes

Sx:
-same sx as focal w/o impairment, but these pts cannot talk to you.
-confusion and tiredness follow seizure for about 15mins

11

Generalized onset seizures: Absence
-aka
-what?
-onset
-duration
-consciousness?

aka: "petit mal seizures"

What: non-convulsive epileptic events

Onset: typically occur in childhood and cease in adulthood.

Duration: onset and termination of attacks are abrupt

Consciousness: disturbances in consciousness; impairment so brief pt is unaware of it, lasts 10seconds

12

Generalized: Absence seizures:
-typical manifestations

-blank stare
-motionless
-stop talking mid sentence
-mild clonic, tonic, or atonic components
-may have automatisms
-no postical period

13

Generalized: Atypical absence seizures
-onset
-duration
-appearance
-consciousness?

onset: gradual onset

duration: do not resolve abruptly

appearance: loss of muscle tone in neck and face. twitching of mouth...

consciousness: may not have an altered level of consciousness.

14

Generalized Myoclonic Seizure:
-what is this?
-most common time of occurrence?

What: rapid recurrent brief muscle jerks that can occur:
-bilaterally
-unilaterally
-synchronously
-asynchronously
*may terminate into generalized tonic-clonic seizure

Most commonly occur shortly after waking or while falling asleep

15

Generalized: Atonic seizure
-aka
-characterized by what?

-aka: "drop attacks"

-characterized by sudden loss of muscle tone that may result in falls with self-injury

16

Febrile Seizures
-most common in who?
-temp is usually what?
- what are the 2 types?
-appearance
-tx

Fever is most common cause of convulsions in children.

temperature is usually greater than 38 (100.4)

2 types: simple and complex

appearance: body becomes stiff and arms and legs twitch, lose consciousness, Simple lasts 15mins or less, complex lasts greater than 15minutes and happens multiple times in 24hr period

tx: IV lorazepam

17

Tonic Clonic Seizure
-aka
-what?
-cause

aka: Grand Mal

What: major motor seizure involving all extremities and characterized by sudden loss of consciousness.

Cause: may be primary arising from deep brain structure or represent a focal seizure with secondary generalization

18

tonic clonic seizure:
-what is tonic?
-what is clonic?
-appearance
-describe the postictal scene
-postictal sx

Tonic: rigid, LOC, collapse, respiratory arrest
*this usually last less than 1 min*

Clonic: jerking
*may last 2-3 minutes*

Appearance:
-tongue and lips may be bitten
-urinary or fecal incontinence
-injury may occur

Postictal scene:
-may recover consciousness, drift into sleep, have further convulsions w/o recovery of consciousness between attacks (status epilepticus)
*have no memory of this

Posticatl sx:
-HA
-disorientation
-confusion
-drowsiness
-nausea
-sore muscles

19

Secondary Generalized Seizure tonic clonic:
-what is this?
-dx
-tx

seizure that becomes generalized (spread to both sides of brain) after the initial event (focal seizure) has already begun.

dx: EEG and MRI

tx: carbamazepine

20

Post traumatic epilepsy
-what?
-most common causes

What: seizures post trauma, depends on degree of head injury

Causes:
-penetrating head wounds
-cerebral contusion
-intracerebral hematoma
-unconsciousness or amnesia lastin more than 24hrs

21

Objectives of Seizure Dx

-determine if pt has epilepsy
-classify the seizure and type of epilepsy accurately and determine if the clinical data fit a particular epilepsy syndrome.
-identify, if possible, a specific underlying cause

22

What 4 conditions can mimic a seizure? What is each?

-REM behavior disorder: sudden arousals from REM sleep immediately followed by complicated often aggressive behaviors for which the pt is amnestic

transient ischemic attack

Transient global ischemia: short term memory deficit without other cognitiev or motor impairment

Migraine

23

Seizure WOrk up:
-what is the most important dx test?
-what labs might you order?

-eeg; classifies seizures, identifies epileptic syndromes, helps in making therapeutic decisions

-MRI and CT as alternative

Labs:
-anti-epileptic drug levels (AED)
-CMP, TSH, CBC, drug screen, glucose
-LP
-EKG

24

Status Epilepticus:
-what?
-causes
-tx

WHat: any seizure lasting greater than 30 minutes or prolonged flurry of seizures without return to previous level of consciousness between seizures
*life threatening, especially if generalized tonic clonic status

Cause:
-drug noncompliance or sudden withdrawl
-fever
-alcohol or drug withdrawl

Tx:
-ABC's
-IV thiamine and glucosse
-Ativan(lorazepam)
-fosphenytoin
-phenytoin
if the above are ineffective: phenobarbital or depacon ....if these fail; general anesthesia w/ ventilator assistance with NMJ blockade

25

All seizure tx
-provoked vs unprovoked

Provoked: tx underlying cause

Unprovoked:
1st seizure = no tx

2nd seizure = diagnosed with epilepsy and treat

other tx options:
-medication

-surgery; Anterior temporal lobectomy, corpus callostomy, amygdala-hippocampectomy

-ketogenic diet: high fat; low carb

-vagal nerve stimulator: implantation of device to stimulate vagus nerve to abort seizure

-biofeedback

26

Seizure Tx
-3 basic MOA of medications

1.Voltage dependent Na or Ca channels:
-Na channel blockers effective for tonic-clonic and partial seizure
-Calcium channel blockers effective for absence seizures

2. Increasing inhibitory neurotransmission (GABA)

3. Decreasing excitatory neurotransmission (glutamate and aspartate)

27

Seizure Tx
-common medications & therapeutic plasma conc.
-serious SE

-Dilantin (phanytoin) (first line focal and generalized tonic clonic, plasma conc= 10-20mcg/mL)
*Na and Ca channel

-Tegretol (carbamazapine, 1st line for focal and generalized tonic clonic) Plasma conc = 4-12mg/L
--may cause toxic epidermal necrolysis & steven johnson syndrome
*Na channel

-Depacon (1st line focal, generalized tonic-clonic, absence, myoclonic, atonic, and atypical absence) --Plasma conc = 50-100mg/L
--BBW: liver dysfunction less than 2yrs old
*GABA

-Phenobarbital (2nd line for focal and generalized tonic-clonic)
--plasma conc = 15-40mg/L
--SE: suicide
*GABA enhancement

-Zarontin (1st line for absence)
--plasma conc = 40-100mg/L
--SE: bone marrow suppression
*depress motor cortex
Category C

-Valium (diazepam)
-Ativan (lorazapam)
-Klonipin

28

What are the common side effects of the seizure medications?

-lethargy
-memory difficulties
-cognitive or concentration difficulties
-hyperactivity

29

General guidlines for all seizure medications

-baseline Cr
-LFTs and CBC
-newer meds may be less sedating
-start low and slow; titrate up
-never stop abruptly
-dont stop one agent until another has been added
-can D/C drugs if pt is seizure free of 3 years
-pregnant women with epilepsy should continue their seizure medication