Wednesday Lectures, 4/8/2015: Seizures Day

TTHM 11.1 Seizures Day (Tint. Ch. 129, 165, 168, 191)

Fun fact: Pseudoseizures by ICD9 ~ “Dissociative Convulsions”


8a ~ Trauma Conference ~ PM&R (Hurlong)

…basically, Upstate should establish closer relationships with SNFs for social & placement considerations, continue work with multidisciplinary team…


10a ~ Seizure Disorders (Prasad)

Most are convulsive, but may also be absence.

Simple Partial (maintains consciousness)

Complex Partial/Generalized (consciousness lost or impaired)

Be careful of label “noncompliant”, associated c stigma when medication difficulties may be dt lack of understanding by pt… ACDs also associated c significant side effects leading to lack of tolerability by pt.

Ketogenic Diet may be helpful in childhood epilepsy?

Prolactin level within ~20 min may help distinguish from nonepileptic Sz, & EEG may distinguish acutely.


1030a ~ Status Epilepticus (Paolo)

*Diagnose: Convulsing or not… “5 MIN” is “STATUS”!

Treat, Benzo, AEDs, B6, intubate & propofol.

Status can be nonconvulsive AMS.  25% of Coma pts found on EEG to be nonconvulsive status.

Critical underlying illness in ~14% of nonconvulsive status.

Which benzo best for Seizures? Lorazepam slightly better than Diazepam per Cochrane 2014.

Although prehospital IM Versed seems to work slightly better than Ativan? Quicker?

Meta Analysis of 2nd line agents… Keppra > Phenytoin, but Valproate even better?! Phenobarb also very good but much more respiratory suppression.

Propofol can cause “PIS” ~ propofol infusion syndrome, usually after complex prolonged polypharmacy… & sedation associated c worse general outcomes, independent of underlying illness?!


11a ~ Small Groups (Barus, KNacca) LP & CSF studies…

SIM INH B6, & Peds Sz Jeopardy


12p ~ Rapid Procedure Lab (Vatti) Fiberoptic intubations


1230p ~ Jr/Sr Sessions (Lavoie, Paolo)

Lumbar Puncture needs INR<1.4 or Plts <50K (?80K) & consideration of other anticoagulation risks. Aim L3~L4~L5, a little lower in peds potentially (stay below L3)


130p ~ CNS Infections (Lavoie)

Meningitis ~ bimodal distribution… mostly children under 5, also old ppl.

Only ~4% is bacterial, mostly viral causes.

(Strep pneumococcus, H.flu, N. meningococcus, …also consider listeria in young & old)

If you suspect bacterial meningitis, give antibiotics. Early is better.

Steroids plus or minus, poor evidence for benefit, unlikely harm unless Vanco levels affected.

Ceftriaxone probably first, Acyclovir…

Droplet precautions until Neisseria excluded.  Close contact prophylaxis c 1 dose Cipro vs 4 dose Rifampin.


2p ~ Tox Seizures (Marraffa) ~ multifactorial, caused by:

*Adenosine down (antagonism) ~caffeine, theophylline

*GABA down (inhibition or depletion)

*Na down (blockers) ~buproprion, carbemaz, citalopram, “caine” drugs, TCAs, propranolol

*EAA up (Excitatory Amino Acids) ~cocaine, EtOH/benzo withdrawl, amphetamines

*ACh up (cholinomimetic & acetylcholinesterase inhibition)

~23% Buproprion! in Sz by drug type.  Other, Antidepressants, Diphen, Tramadol, TCAs, Amphetamines, Venlafaxine…

Serotonin agonism may ~ SIADH, hyponatremia

INH needs B6! Think about B6 after 2nd line attempt!!! Similar c gyromitra & methylhydrazine

B6:INH 1:1 or 5 grams (50 vials) or 70mg/kg in peds…

higher doses of B6 can have toxicity though?! & synergistic effect c additional benzos


230p ~ Febrile Sz (Hanley)

Simple Febrile Seizure needs:


*<15min (Neuro Lit says 30min)

*Age 6mo~5yrs


*no recurrence within 24 hrs, nor persisting/focal neuro abnormality

For concerns about bacterial source of fever, CXR & UA likely more useful than other labs.

Remember though, ~1/3 of febrile Sz are complex & have limited evidence or guidelines.

…?LP?… consider status after recovery.  Good return to baseline may indicate low risk & LP can be avoided in some cases based on Hx & Sx factors.

After checking glucose: 2 doses benzos, 5 min ea, then consider phenobarb, or fosphenytoin 20 mg/kg (>phenytoin dt vascular irritation, hypotension, arrhythmia risk), keppra?/depakote?/B6/intubation.


3p ~ Neonatal Sz (Thabet)

Most neonatal Sz are NOT neonatal epilepsy (syndromes).

Focal, clonic? Did it stop with restraint?

Hiccups or apparent tics, pedaling or cycling of legs can be concerning.  True seizures do not resolve c restraint.

Neonatal period most common frequency of seizure onset per unit time, & phenobarb common 1st line, don’t forget B6, & high mortality, up to 20%!?!


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