Julie Jaffray, MD Emily Pollakowski, MD. Transient Involuntary Alteration in consciousness,...
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Transcript of Julie Jaffray, MD Emily Pollakowski, MD. Transient Involuntary Alteration in consciousness,...
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Julie Jaffray, MDEmily Pollakowski, MD
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Transient Involuntary Alteration in consciousness, behavior, motor
activity, sensation or autonomic function Due to abnormal electrical neuronal
discharge in cerebral cortex Signs and symptoms depend on location of
discharge
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Febrile Partial
◦ Simple partial◦ Complex partial
Generalized◦ Absence◦ Myoclonic (muscle twitching)◦ Clonic (rhythmic shaking)◦ Tonic (rigid contracture)◦ Atonic◦ Tonic-clonic
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Seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of the central nervous system◦ No previous neonatal seizure or previous
unprovoked seizures Vast majority are benign and rarely cause
brain damage Usually due to a rapid rise in temperature
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90% of febrile seizures occur between 6 months and 3 yrs of age
2-5% children will have a febrile seizure at some point
Simple febrile seizures (70-75%)◦ Single, brief (<15min) generalized seizure during
fever without intracranial infection or other causes and self resolves
Complex febrile seizures◦ Lasts >15 min, focal, reoccurs within 24 hours
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Onset of seizure in a limited area, or one cerebral hemisphere
No impairment of consciousness Highest incidence after 1 year of life Risk of reoccurrence is higher than with
generalized seizures Can be sensory, motor or autonomic Any structural lesion can causes SPS
◦ Vascular, meningitis/encephalitis, trauma, tumors, hypoxic insult, postsurgical changes, metabolic/electrolyte shifts, endocrine disorders, meds/toxins
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Starts focally within the brain then causes impairment of consciousness
Most commonly a manifestation of temporal lobe epilepsy
Typically last 30 sec-2 mins Patient can describe an aura Can be autonomic, simple motor, complex
motor, negative (aphasic, atonic, hypomotor)
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Type of generalized seizure-not conscious Brief, usually frequent throughout the day
(in childhood absence) Appear later in childhood Staring spells, decline in school
performance Hyperventilation can provoke a seizure
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Occurs in several epilepsy syndromes Initiated by 3 mechanisms
◦ Abnormal response of a hyperexcitable cortex◦ Primary subcortical trigger◦ Abnormal innervation from subcortical structures
May have a prodrome hours to days prior to seizure◦ Mood changes, light headedness, anxiety, sleep
disturbance, difficulty with concentration Postictal state
◦ Variable period of consciousness, gradually wakens usually confused
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Any continuing type of seizure, but usually refers to a generalized convulsive state
Seizure lasting more than 30 mins◦ Continuous or multiple seizures without gaining
consciousness Can lead to hypertension, tachycardia,
cardiac arrhthmias and hyperglycemia Mortality is 20%
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Neonatal seizure◦ Can be tonic, clonic, myoclonic or subtle (blinking,
chewing, bicycling, apnea-due to immature CNS)◦ Usually a symptom of acute brain disorder
Hypoxic-ischemic encephalopathy Intracranial hemorrhage/infarction CNS infection CNS malformation Metabolic (hypoglycemia, hypocalcemia, toxins) Inborn errors of metabolism
Infantile Spasms◦ Head nodding and flexion or extension of trunk and
extremities◦ Often in clusters◦ Onset 2 months, peak 4-6 months
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Intracranial infection (meningitis, encephalitis)
Intracranial tumor (benign or malignant) Injury causing intracranial hemorrhage Metabolic disturbances (hypoglycemia)
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Status Epileptus Defined as > 30 minutes of continuous
seizure activity or 2 or more sequential seizures in 30 minutes without full recovery of consciousness between seizures
Prepare for status with every seizure you witness
-Medication dosing-Differential diagnosis
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Before anything else…A B C! Airway Breathing Circulation Stabilize patient Establish access and obtain labs
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Airway
-Appropriate positioning-Open airway, using head-tilt/chin-lift-If suspected head/Cspine trauma, jaw thrust-Rule out obstruction
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Breathing
-Evaluate air exchange-Look and listen-Abnormal chest wall dynamics-If actively seizing: oxygen-If hypoventilating: ambu bag ventilation-Concern for aspiration
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Circulation
-Rate Goal HR >100bpm (infant), >60bpm (child)-Rhythm -Assess pulses (central and peripheral)-Assess capillary refill-IV access, send off labs
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Diazepam 0.5mg/kg IV/PR (max 6-10mg) Check FSBS (if possible) D10 bolus, 5mls/kg-use 20ml syringe: 4ml D50 + 16ml NS-repeat for full weight-based dose Repeat diazepam if still seizing 5-10
minutes later Think about next step
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Phenobarbital Loading dose: 15-20mg/kg IV, then 5mg/kg
q 30 minutes to max 30mg/kg Maintenance: 5mg/kg/day IV, either BID or
daily
Phenytoin/Fosphenytoin Loading dose: 15-20mg/kg IV Maintenance: 5mg/kg/day IV, divided BID,
may increased to 8mg/kg/day
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Important to monitor closely during administration of above medications
Vitals (RR, HR, BP) Level of consciousness
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Diazepam-Respiratory depression-Hypotension
Phenobarbital-Respiratory depression-Hypotension
Phenytoin-Hypotension-Arrythmias
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Stabilize the patient Stop the seizure Determine etiology (labs, imaging) Eliminate precipitating factors Reverse correctable causes Observe Determine long term plan and need for
daily AED
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Too many drugs to remember! Choice of AED depends on seizure type Start with monotherapy, as 75% children
with epilepsy will be, fully controlled Polypharmacy is more expensive, decreases
compliance, increases risk of toxicity