meidicine. first seizure.(dr.muhamad tahir)

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The Management of the First Seizure

Dr Mohammed Tahir

٢/١٨/١٢ Dr Laura Martin (with a little bit of help from Tony Holley)

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Aims

• To have an understanding of the common causes of a first seizure presenting to the Emergency Department

• To have an understanding of the basic management of the first seizure

• To have some basic rules for seizure management

/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of help from Tony Holley)

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Definition of Seizure

An episode of abnormal neurological functioning caused by abnormal discharge of neurons!


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Classification of Seizures

• Generalised - loss of consciousness• Partial - no loss of consciousness• Unclassified


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Classification of Seizures

Generalised• Absence• Tonic Clonic• Myoclonic• Clonic• Tonic• Atonic

PartialSimple Partial•Motor•Sensory•Autonomic

Complex Partial•With psychic, cognitive or affective symptoms

•With automatism's

Partial seizures with secondary generalisation


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Classification of Seizures by Etiology

• Acute Symptomatic seizures• Remote Symptomatic seizures• Idiopathic


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Acute Symptomatic seizuresCNS infections•Meningitis•Encephalitis•Abscess

Vascular disease•CVA•Vasculitis

Trauma

Hypertensive

Eclampsia

Neoplasms•Benign•Malignant - Primary,

Secondary

Metabolic•Electrolyte disturbances•Hypoglycaemia•Hypoxia•Renal Failure


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Acute Symptomatic seizures- Toxin Drugs

Tricyclic antidepressantsAntidepressantsTheophyllineWithdrawal - ETOH, benzo’sAnticholinergicsOrganophosphates

CocaineAmphetaminesLignocaineAnti -psychoticsAntihistaminesIsoniazid


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Remote Symptomatic Seizures

• Previous head injury• Previous CVA• Congenital CNS disorders• Previous hypoxic injury• Previous CNS infections• Degenerative diseases


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Incidence & Epidemiology

• 5% of the population have a seizure some time in their life

• Bimodal frequency• adult 1st generalised seizure accounts

for 1% ED visits


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Causes of seizures presenting to Emergency Departments

Cause Sempere et al 1992 Henneman et al 1994

Idiopathic 27.6% 44.0%

Infarction 23.5% 11.0%

Cerebral Cystercercosis - 12.0%

ETOH 11.2% -

CNS infections 9.2% 10%

CNS tumour 8.2% 7.0%

Vascular Malformation 6.1% -

Trauma 4.1% 4.0%

Drug toxicity 3.1% -

Hyponaetraemia 2.0% 2.0%

Systemic Infection - 2.0%

Other 5.0% 9.0%


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Causes of seizures by age

Cause Age < 45 years Age > 45 years

Idiopathic 45% 15.5%

Infarction 2.5% 37.9%

ETOH 15% 8.6%

CNS infections 17.5% 3.4%

CNS tumours 2.5% 12%

Vascular Malformation 7.5% 5.2%

Trauma 7.5% 1.7%

Drug toxicity 0% 5.2%

Other 2.5% 10.2%

Sempere et al 1992


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Causes of seizures by age - acute symptomatic seizures

• 6/12 to 5 years -Febrile convulsions• Young adults -Trauma 26%

-Drug withdrawal 20%

• Elderly - CVA 44%

Annegers et al 1995


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Presentation to the Emergency Department

Differentiated• Febrile convulsion• Idiopathic epilepsy • Acute symptomatic

seizures• Remote Symptomatic

seizures

Undifferentiated• Cardiac Arrhythmia's• Vasovagal Episode• Cardiac - Structural• Blood loss• Postural Hypotension• Sepsis• Psychogenic• etc


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Presentation to the Emergency Department

• Has the patient had a seizure?• What kind of seizure was it?• Was there a focal component?• Was this the first seizure?• Is there a family history of seizure

disorder?• Why did the seizure occur?


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Other Important History

• Systemic illness• drug use/abuse• pregnancy• mental retardation• head injury• unexplained bruises/tongue biting• nocturnal enuresis• precipitants


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Management

• Historical documentation of the seizure• Physical examination• Investigations• Cessation of seizures• Observation• Disposal• Advice• Seizure Prophylaxis• Follow up/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of

help from Tony Holley)

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Investigations


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Rule

Always do a glucose on any one who is having a seizure or has had a seizure!


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Scenario 1

• 17 year old girl• Post first witnessed tonic clonic seizure• Been out to a party the night before• Uncle has epilepsy• Now well, GCS 15, Vital signs normal• Neurological exam normal


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Investigations

• Glucose• Sodium• Calcium• Consider urine and pregnancy test• CT [ MRI ] & EEG as outpatient


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Post first seizure advice

• Management of a seizure at home• Safe activities• Driving• Who should know?• Have I got epilepsy?• Not life threatening• Exacerbating factors• Follow up


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Seizure recurrence

• Most common within the first 6 months• More than 50% of those who have

recurrence will occur within 6 months• Rate varies from 36 -77%


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Seizure recurrence increased if

•Symptomatic Seizure•History of epilepsy in a sibling•Todd’s paralysis•EEG abnormalities•2 seizures - 80-90%


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RULE

Seizure prophylaxis for all first symptomatic

seizures


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Scenario 2

• 50 yr old woman• Post tonic clonic seizure• Husband said twitching started in her R

arm, then progress to LOC.• History of recent headaches.• Now well, GCS 15, appears neurologically

intact• Vital signs normal/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of


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RULE

ALWAYS LOOK IN THE FUNDI


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RULE

First Focal Seizure = CT scan!!!!!!


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Scenario 3

• 50 yr old woman• Post generalised seizure • Previously well, no seizures in the past• Recent headache for 24 hours, unwell & fever• Now GCS 13, Temp 39.8• Confused, unco-operative 30 minutes post

seizure• Moving all limbs.


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Who to CT?

• Focal seizures• trauma• anticoagulants• alcoholics• immunosuppressed• fever,stiff neck,persistent headache• focal neurology


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RULE

Do not LP a patient who has a decreased Glascow

coma score!!Treat first, CT & ask

questions later!!/ /٢ ١٨ ١٢ Dr Laura Martin (with a little bit of


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RULE

A GCS < 13 is a relative contraindication to LP

even after a normal CT!!


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Scenario 4

• A 75 yr old man• Previous hypertension• Post tonic clonic seizure• Now GCS 15 but right arm weakness


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RULE

Focal neurology = CT scan

Focal neurology does not = LP


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Scenario 5

• 18 yr old man• Rugby injury with LOC, scalp laceration• Initially in ED GCS 15, vomited twice

and complaining of a headache• Has tonic clonic seizure in ED. Self

resolved• Now GCS 12 - 2 minutes post seizure


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RULE

Trauma & Seizure

= CT scan!!


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Status Epilepticus

• Continuous or repetitive seizures without time for recovery

• neuronal injury can occur in less than 30min

• may be subtle


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RULE

• BEWARE THE INTER-ICTAL PATIENT


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Treatment of Status Epilepticus

• All patients who still fitting on arrival to ED

• fitting for more than 10min• LONGER THE DELAY HARDER TO

CONTROL


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0-5 minutes

• Confirm diagnosis• Oxygen• Airway & Breathing [ Consider ETT ]• Vital signs• IV access• Glucose check• Oximetry• Lab


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5-10 minutes

• If hypoglycaemic treat• Adults 100 mg thiamine followed by 50

mls 50% glucose• Children 2 mls/kg 25%


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10-20 minutes

•0.1 mg/kg lorazepam at 2mg/min up to 4 mg total

or•0.2 mg/kg diazepam at 5mg/min up to 20mg/min

Diazepam must be followed by a loading dose of phenytoin


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Difficult access?

• IM midazolam 10mg• PR diazepam 0.5 mg/kg• PR lorazepam 0.1mg/kg


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20+ minutes

• Load with phenytoin 20 mg/kg no faster than 50 mg/min in adults and 1mg/kg/min in children

• IV fluids must be N Saline


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If Status continues

• 1. Additional phenytoin 5 mg/kg up to a total of 30 mg/kg

• 2. Midazolam load 0.2 mg/kg infusion • 3. Phenobarbitone 20mg/kg at max 100mg/min• 4. Proprofol load with 0.2mg/kg then infusion• Expect apnea• Intubation will be required - rapid sequence

induction with thiopentone and suxamethonium


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Admission criteria for a first seizure

• Acute Symptomatic Seizure requiring ongoing treatment & investigation

• Febrile seizure where underlying cause needs treatment or fever does not settle

• Focal seizure

• Status epilepticus or prolonged seizure.

• Recurrent seizures• Social Situation


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Conclusion

No one seizure is the sameThe clinician must always think of the underlying cause & investigate & treat

appropriately


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References

• Em Clinics N America Feb 1999 17;1• Emergency medicine reports Vol 18;14

1999• Neurology Nov 1999 S4• Lancet July 2000 Vol 356


meidicine. first seizure.(dr.muhamad tahir)

Health & Medicine

dr laura martin

tony holley

amp

seizure

rule

seizures

gcs 15

loss