Jason HaagIntern Conference

Case34 y.o. with h/o seizure disorder presents to

ED with increased seizure frequency. He states he’s had 4 tonic-clonic seizures over the past 24 hours.

He has a 6 year history of epilepsy treated with carbamazapine 400 mg po bid. He notes increased nausea, vomitting, and diarrhea over the last week which made him unable to take his meds.

No fever, new medications, trauma or alcohol abuse

CasePhysical Exam

Mildly low BP (100/60)Lethargic, but able to follow commandsLateral tongue bites notedNeuro exam unremarkable

LabsWBC 12, Na 132Otherwise wnl

CaseAs you finish your exam the patient begins to

have a tonic-clonic seizure lasting 2 minutes

What do you do right now????

What are you thinking is causing the seizure???

Work up???

EpilepsyWhat is it?

Tendency to have recurrent unprovoked seizures (2 or more)

How common is it?Common, about 2.5 million people in US

Common presentation complaintsNew seizure or increased frequency of seizures

EpilepsyTypes of seizures

Localization related seizures Partial or focal

Start in one part of brain and may spread Simple or complex

Simple = normal awareness Complex = impairied awareness

May progress to generalized seizureGeneralized seizures

Involve both hemispheres of the brain at onset

EpilepsyStatus Epilepticus

5 minutes of persistent seizures Or a series of recurrent seizures without a

return to full consciousness betweenDoes not have to be tonic-clonic seizure

Nonconvulsant states can be in status i.e. absence, complex partial seizures

1st Seizure EvaluationSeizure causes

Head traumaBrain tumorCVAEncephalitis/MeningitisHypoglycemia/nonketotic hyperglycemia (HONK)Hyponatremia/HypernatremiaHypocalcemia, hypomagnesiumUremiaHyperthyroidismAnoxiaEtoh/benzo withdrawal

1st Seizure EvaluationSeizure imitators

SyncopePsych d/oSleep d/o (narcolepsy)MigraineTIAs

1st Seizure EvaluationWork up

Chemistry, thyroid functionProlactin (?)LP

If concerned about infectionNeuro imagingEEG

Often normal or nondiagnostic

Acute Management of SeizuresGoals

Prevent aspiration/trauma

Terminate seizure

Prevent future seizures

Acute Management of SeizuresWhat to do

Place patient in lateral decubitus position with head elevated at 3o degrees (lessen risk of aspiration)

Give oxygenAccucheck

If low 1 amp D50 If h/o EtOH use give thiamine first

Lorazepam .1 mg/kg total given in 2 mg increments May repeat every minute Can be given IV or IM, though better IV Can give rectally, but here we just don’t need to

Acute Management of SeizuresCan load with IV phenytoin 15 mg/kg

IV infusion rate 50 mg/minWatch for hypotension and arrythmiasIf allergic, can load with phenobarbital,

valproate, levetiracetam

Status EpilepticusIf seizures persist consider

IntubationLorazepam gtt

.1 mg/kg/hrCan use propofol gtt

Watch for complications of status epilepicusLactic acidosis, hyperreflexia, electrolyte

abnomalities, rhabdomyolysis and renal failure

Antiepileptic DrugDecision typically made by NeurologistKnow common drugs and side effects

Medication Metabolism

Seizure Efficacy

Adverse Effects

Carbamazepine Hepatic Partial Bone marrow suppresion, hepatitis, low Na

Phenytoin Hepatic Partial Gum hyperplasia, rash, hirsutism, nystagmus

Valproate Hepatic Generalized Weight gain, alopecia, tremor, hepatitis, low platelets,

pancreatitis

Levetiracetam Renal Generalized Behavioral changes

CaseWhat do you do right now????

Lorazepam IV +/- antiepletic

What are you thinking is causing the seizure???Electrolytes, thyroid function wnlCarbamazapine level subtherapeutic

Work up???Likely does not need imaging (h/o seizure d/o) or

LP