Seizures and their management Presentation.pptx

A brief insight to management of seizures

1. Seizures and Status Epilepticus Management in the Emergency Department

2. Definitions Seizure - burst of uncontrolled electrical activity between neurons or nerve cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors , sensations or states of awareness. Epilepsy – a brain disorder characterised by recurring( atleast 2) unprovoked seizures Status epilepticus - A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes

3. Epidemiology Epilepsy seen in 1/150 people For each epilepsy pt, 1 ED visit every 4 years 1-2 of all ED visits Significant costs

4. Epidemiology Risk of SE greatest at extremes of age Pediatric and geriatric populations Most affected SE occurs in setting of acute insult, chronic epilepsy, or new onset seizure 150,000 cases per year

5. Etiology CNS Infections - meningitis, encephalitis Strokes (bleed, embolism, thrombosis) T raumatic ICH Space occupying lesions E ncephalopathies – Uraemic , hepatic, hypertensive Metabolic: Disorders of glucose, sodium, calcium, tonicity (hyper/hypo), acid base Withdrawal states – alcohol, benzodiazepine, barbiturate Toxins – TCA, propanolol , theophylline, anticonvulsants, tramadol, organophosphates Illicit drugs – cocaine, MDMA, other stimulants Environmental – hyperthermia/heatstroke

6. Mechanism abnormal neuronal discharge with recruitment of otherwise normal neurons, due to loss of GABA inhibition

7. Pathophysiology Glutamate nuerotransmitter , which is secreted in huge amounts acts as a toxic mediator resulting in necrosis of nuerones Necrosis will occur even if systemic problems are treated (HTN, fever, rhabdomyolysis, resp acidosis, hypoxia) Early compensation for increased CNS metabolic needs Decompensation at 40-60 minutes, associated with tissue necrosis Over 40-60 min, loss of metabolic compensation If SE not managed leads to systemic hypotension and Cerebral blood Flow drops

8. Seizure Classification Generalized - both cerebral hemispheres affected Partial - one cerebral hemisphere affected

9. SE Classification

10. GCSE Generalized convulsive SE, withtonic-clonic motor activity Non-GCSE Types Non-convulsive SE Absence SE Complex-partial SE Subtle SE Late generalized convulsive SE Coma - persistent ictal discharge, very grave prognosis

11. Altered Mental State in Seizures Mental status should improve by 20-40 mins If pt comatose, then subtle SE is possible Up to 20 of pts with coma still are in SE EEG monitoring crucial

12. Management in Emergency Department Identifying and understanding the various type of seizures often guides clinical management. Management of seizures in the ED has three components: Terminating the seizure Managing the post ictal state and associated sequellae , and Preventing further seizures.

13. ABCs Abort seizure E valuate potential cause of seizure Consider the list of etiologies (non-exhaustive) Key abnormality in most case is hypoglycaemia REMEMBER TO ALWAYS DO A GLUCOMETER CHECK FIRST! Address cause – correct hypoglycemia Rapid sequential use of anti-convulsant drugs

14. REMEMBER IF NO IV ACCESS: PR diazepam IM midazolam IM fosphenytoin Buccal, intranasal midazolam NB No IM phenytoin/phenobarbital

15. Investigations Bloods: FBE; U&E; LFT; CMP Biochem : Lumbar Puncture ( Fever and CSF pleocytosis can occur in SE withoutmeningitisUse C linical criteria for LP Altered mental s tate I m m unocompromise Me ningismus Imaging: Neuroimaging CT brain scan non-contrast( use contrast if suspecting intracranial mass) – useful for focal seizures MRI- complements plain CT and useful for refractory seizures ECG(QT interval) EEG studies - to rule out subtle SE, coma

16. Admit if: Multiple seizures or status epilepticus Prolonged post ictal confusion, or focal neurological deficit Investigations reveal underlying condition that requires treatment Discharge if: Patient has normal physical examination and investigation results and is observed for a period of time determined by a senior ED staff determined by circumstances.

17. A Case on Post stroke seizures 31/F P/C – multiple seizures for 27 years Background- managed for meningoencephalitis at age 3 Developed seizures post meningoencephalitis Now more frequent Lasting 2-3 mins Pre- ictally bouts of anger and violent behaviour Ictally tonic clonic seizures Post- ictally drowsiness Associated delayed and unachieved milestones during child development Is taken care of by grandparents

18. On examination: Alert and stable Multiple Scarring noted on body with fresh bruises on forehead Postured left upper limb Mental state equivalent to that of a child Rest of systems normal Mx: initiated on anticovulsants Counselled family Booked physician clinic for review

19. THE END. Thank you!