acute fits

Dr Al Buick

Royal Devon and Exeter Hospital

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The Management of Acute Fits

Meducation The Medical Education Network www.meducation.net

Outline•What do we mean by acute fits?• Different types of seizure• Causes of seizures•Management of acute seizures• Complications of seizures• Some quick cases


Definitions – what does it all mean!

Acute Fits EpilepsyStatus

Epilepticus




Epilepticus

What we might also call an acute seizure



A prolonged seizure or seizures repeated frequently enough to prevent recovery between episodes occurring over a period of 20-30 minutes.


Epilepticus



Recurrent episodes of intermittent brain dysfunction due to a sudden, disorderly, and excessive neuronal discharge. This can manifest as a seizure.


Epilepticus

Different types of seizure


Seizures

Partial Generalised

Simple Complex

Absence Myoclonic Tonic-Clonic Tonic Atonic


So what can cause a seizure?

Causes of seizures- Intracranial

Underlying brain pathology

• Underlying brain abnormality• Raised intracranial

pressure• Cerebral tumour• Cerebral oedema• Pregnant – Ecampsia

• Stroke• Thrombo-embolic• Haemorrhagic

• Brain infections


GIANT CELL TUMOR, 14 MONTHS WITH SEIZURES

Extracranial- We could all suffer fits given the right situation

Pyrexia

Biochemical• Sodium, Glucose • Calcium, magnesium• Urate

Hypoxia – (e.g. Carbon monoxide poisoning)

Causes of seizures- Extracranial

Drugs• Prescribed• Recreational• Withdrawal

Management of seizuresYou are the F1 on call and it is 3am. You receive a bleep from one of the wards….

“Could you come and see this patient….. they are having fits and we don’t know what to do….. Please

come quickly…”

Management


A

B

C

D

Airway

Breathing

Circulation

Disability

Is their airway patent?Give airway management if needed

Management


A

B

C

D

Airway

Breathing

Circulation

Disability

• What is the respiratory rate?• What are their oxygen saturations• Give oxygen if needed

Management


A

B

C

D

Airway

Breathing

Circulation

Disability

• Heart rate• Blood pressure• Peripheral perfusionCapillary refill time

Management


A

B

C

D

Airway

Breathing

Circulation

Disability

• Other signs• ? Head injury• ? Bleeding• ? Sign of infection

Don’t Forget Glucose

Management of fits – Stepwise appraoch


Initial A,B,C,D

Benzodiazepine

Phenytoin

Paralysis and

ventilation

Start treating underlying

cause

Benzodiazepine


If fit does not resolve after a few minutes consider giving a benzodiazepine

Action Enhance effect of GABA which is the main inhibiting neurotransmitter Therefore reduce the excessive neuronal discharge

Benzodiazepine


Side effects to be aware of Sedating and muscle-relaxing action Suppressed breathing Hypotension (worse with IV) Reduced conscious level Nausea Euphoria


BenzodiazepineDrug Peak onset Half life

Midazolam About 1 hour Short (3 hours)

Lorazepam About 3 hours Medium (15 hours)

Diazepam About 2 hours Long (30+ hours)

Chlodiazepoxide About 3 hours Long (30+ hours)



Initial A,B,C,D

Benzodiazepine

Phenytoin

Paralysis and

ventilation


cause

PhenytionWorks on sodium channels Blocks voltage-sensitive sodium channels in neurons Delay in neuronal electrical recovery from inactivation Inhibitory effect is dependent on the voltage and frequency of neural cell firing by selectively blocks neurons that are firing at high frequency

PhenytionPharmicokinetics Mainly hepatic break down Zero order kinetics

PhenytionSide effects

Beware of toxicity as zero order Arrhythmias (it is a class 1b antiarrhyhmic)

Bradycardia HypotensionBradykinesia, ataxia Sedation, confusion Teratogenicity



Initial A,B,C,D

Benzodiazepine

Phenytoin

Paralysis and

ventilation


cause

Paralysis and ventilation

If seizure not managed by the initial methods

Amy need to consider paralysis and ventilation Should be done in ITU Expert help required

Complications of Seizures

SUDEP - Sudden Unexpected Death in Epilepsy

Brain injury

Physical Injury• Direct from fit – Tongue biting fitting• Driving?

A few clinical cases…

Case 1A 21 year old diabetic girl presents to the emergency department having been found out shopping on a Saturday morning. She was reported previously well by her friends and had even been out for some drinks the night before.

Her friends tell you she was acting strange and then collapsed. She not not very responsive and 10 minutes later she started fitting.What else do you want to know and what are you going

to do?

Case 2A 84 year old woman is brought in by ambulance having been found at home by her son on the floor. She was unresponsive and has been fitting on an off since she had been found.

Her son reports she is normally fit and well and only has bad arthritis, recently given “some sort of patch of the pain”

What else do you want to know and what are you going to do?

Case 3

A 20 year old motorcyclist was found having crashed in to a wall. He was brought in by air ambulance. He is barely conscious but responds to pain.

He is fitting every 5 minutes and has been for 45 minute since he was found.

What else do you want to know and what are you going to do?

QUESTIONS

acute fits

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