Adult Seizure Management for the Family Practitioner

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Adult Seizure Management for the Family
Practitioner

• Huey Lin, R3
• Swedish Family Medicine
• December 2001

2
Case - Charlie B or C Brown

• 27 year old male who I saw in saw in clinic in
  February 2001 for back pain who was recently
  admitted for change in mental status.
• 5-10 seconds of blurry vision -gt resolved. Then
  30 minutes later, asked to help a co-worker.
  From this point on, no memory of what happened.

3
Case continued

• From co-worker
• Chas came to help me and I noted his shirt was
  wet. He sat down next to me. Then the gum he was
  chewing fell out of his mouth, and he was
  drooling. I couldnt snap him out of it - even
  after shaking him. He then got back up and weaved
  around the room a little before sitting down next
  to another co-worker.

4
Case continued

• Another co-worker
• Charles then sat next to me, and seemed dazed.
  When I asked him where he was, he kept on saying,
  yeah, yeah, yeah for some time. He then seemed
  to recognize me, and thats when we called the
  paramedics. It was very, very odd. I think hes
  into something ltwink, winkgt

5
Case continued

• From the ER MD
• Mr. Brown came in about 30 minutes after his
  event. He seemed lucid, coherent. He was
  complaining of a headache, and the first thing he
  remembers is talking to Mr. Van Pelt.
• He had no visible trauma and had not lost
  continence. We drew the usual labs and did the
  complimentary head CT - but only one per visit.

6
Case continued

• Yeah, I felt pretty good by the time I got to the
  ER. I knew what was happening.
• Something like this has happened to me before,
  but Ill tell you more about that later.
• I was in a car crash in spring 2000 and my noggin
  got a goose egg, but thats about it.
• As to my family, my great grandfather had
  seizures - but he was born really premature.
• And yeah, I admit...I smoke a little weed about
  1-2 times a week.

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Epidemiology of Epilepsy

• Estimated 2-4 million people in the US -- about 1
  of 50 children and 1 of 100 adults -- are
  affected
• Some debate if prevalence higher in children or
  the elderly
• Less than 50 have an identifiable cause
• There is a 9 cumulative lifetime incidence rate
  of seizures but only a 3 cumulative lifetime
  incidence of epilepsy

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Causes of Epileptic Seizures

• Fewer than half of patients have an identifiable
  cause.
• Congenital brain malformations, inborn errors of
  metabolism, high fever, head trauma, brain
  tumors, CVA, intracranial infection, cerebral
  degeneration, withdrawal states, and iatrogenic
  drug causes.

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Common Causes of Provoked Seizures

• Massive sleep deprivation
• Excessive stimulant use
• Withdrawal from sedative drugs or alcohol
• Substance abuse (cocaine, methamphetamine)
• High fever
• Hypoglycemia
• Electrolyte imbalance
• Hypoxia

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Differential Diagnosis of Seizures

• Syncope
• Panic attacks
• Paroxysmal sleep behavior
• Pseudoseizures
• Breath-holding spells

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Basic seizures types

• Loss of consciousness?
• NO
• Simple partial
• YES
• Complex partial
• Generalized tonic-clonic
• Absence

• Cortical area affected
• PART OF CORTEX
• Simple partial
• Complex partial - usually temporal lobe
• ENTIRE CORTEX
• Generalized tonic-clonic
• Absence

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Simple Partial Seizure

• Usually lasts 5-10 seconds most less than a
  minute
• Symptoms dependent on cortical area involved
• No loss of consciousness
• No postictal state
• Difficult to differentiate between psychiatric
  disorders (key is paroxysmal nature and duration
  of seizure)
• EEG - normal or focal spikes

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Complex Partial Seizure

• Most common type of seizures in adults
• Variable duration, but typically less than 3
  minutes
• Appears awake, but not responsive - often stare
  or have automatisms
• If restrained, may become hostile or aggressive
• Postictal period - somnolence, confusion, and
  headache up for up to several hours
• No memory of what took place during seizure
• EEG - focal activity spreading to involve one or
  both hemispheres

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Generalized Tonic-Clonic Seizure

• Usually lasts 1-2 minutes
• Abrupt loss of consciousness, often preceded by
  scream
• All muscles become stiff (tonic) followed by
  twitching/jerking movements (clonic)
• Expect cyanosis, mouth injuries, or other bodily
  injuries
• Can be preceded by any partial seizure
• Postictal period - usually deep sleep with
  hyperventilation then gradual wakening with
  complaint of headache
• EEG - series of generalized, high-amplitude
  spikes

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Absence Seizure

• Usually lasts between 5-10 seconds but
  frequently in clusters
• Considered a seizure disorder of childhood
• Absence before age 5 associated with mental
  retardation and tendency for future seizures
• Sudden staring with impaired consciousness with
  eye blinking and lip smacking for longer seizures
• EEG - characteristic generalized, 3 per second,
  spike and wave

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Epileptic Syndromes and Other Seizure Types

• There are other seizure types such as clonic,
  myoclonic, tonic, and atonic.
• There are epileptic syndromes characterized by
  patterns of clinical features, age of onset,
  family history, and associated neurologic signs
  and symptoms.
• BUT, almost all of the other seizures types and
  all of the syndromes have onset in childhood and
  so will not be reviewed today.

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Clinical Evaluation of Seizures

• HISTORY is the most important part of the
  clinical evaluation. Pointed questions are often
  needed.
• Obtain as accurate of a description from patient
  and witness(es).

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Clinical Evaluation of Seizures

• Before the seizure
• Was there an aura?
• Was there an identifiable trigger?
• If there is a history of seizure, what are known
  precipitants or triggers.

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Clinical Evaluation of Seizures

• During the seizure
• Was there signs of impaired consciousness?
• What was the patient actually doing?
• Was there loss of urine or stool?
• How long did the episode last?
• If h/o seizures, was this a typical/atypical
  episode?

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Clinical Evaluation of Seizures

• After the seizure
• For the observer, was the patient postictal? If
  no observer, did patient know where he/she was,
  what had happened immediately after episode?
• If postictal, how long was it?
• Did the patient have any complaints when s/he
  became more awake?

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Clinical Evaluation of Seizures

• Other history to obtain besides event history
• Medical history febrile seizures, head injury,
  CVA, malignancy, infectious diseases
• Family history febrile seizures, epilepsy in
  close relative, h/o neurological disorders
• Social history travel, occupation, substance
  abuse

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Back to C. Brown...

• Aura? Maybehad blurry vision 30 minutes prior to
  episode
• Trigger? Not identifiable
• Impaired consciousness? Yeah, yeah, yeah
• Good description from witnesses about event
• Loss of continence? Negative dirty underwear
  sign.

• Duration? About 3 minutes
• Postictal? Difficult to say headache, little
  groggy, but claims knew his location immediately
  afterwards
• Medical history h/o minor head trauma, unusual
  episode earlier in month
• Family history yes, but distant relative
• Social history no travel, works in medical
  setting, likes joints

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Back to C. Brown

• With this history, did this gentleman have a
  seizure?
• If so, what type of seizure?

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Seizure Management
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Acute Seizure Management

• Airway
• Breathing
• Circulation

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Acute Seizure Management Status Epilepticus

• Vast majority of adult seizures will complete in
  2 minutes few will go into status epilepticus.
• Status epilepticus is defined as
• one generalized tonic-clonic seizure lasting
  more than 5 minutes
• or
• two generalized tonic-clonic seizures occurring
  in 1 hour

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Acute Seizure Management Status Epilepticus

• Benzodiazepines
• Lorazepam 0.1 mg/kg IV at 1-2 mg/min up to 10
  mg. One protocol lists 4 mg as good initial dose.
• Diazepam - 0.2 mg/kg IV at 2 mg/min up to 20 mg.
  Can also be given ET or PR.
• Midazolam - 2.5-15 mg IV or 0.2 mg/kg IM. Very
  short acting.
• BE PREPARED TO INTUBATE!

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Acute Seizure Management Status Epilepticus

• Fosphenytoin
• Fosphenytoin - 15-20 phenytoin equivalent/kg at
  100-150 mg phenytoin equivalent/min may be given
  IM.
• 20-30 minute onset so must also use smaller doses
  of benzodiazepine
• Give too rapidly and may cause hypotension or
  arrhythmias.

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Acute Seizure Management Status Epilepticus

• Barbituates
• May also be used, but majority of experience with
  this medication is the ER setting with pediatric
  patients on in the ICU setting for refractory
  seizures.
• Still may be useful in adults who are seizing
  because of phenobarbital withdrawal.
• Be prepared to intubate and support blood
  pressure.
• Propofol and phenobarbital are acceptable options
  for treating refractory seizures in ICU setting.
• Get help from a neurologist if you are in the
  ICU.

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Back to Clinical Evaluation

• When the environment is more calm, do a complete
  history and physical exam
• Spend time on a thorough neurological exam
• Correct any suspected underlying causes

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Back to Clinical Evaluation

• Laboratory Data
• Chem 7, Ca, Mg, CBC with differential, toxicology
  screens
• Drug levels if patient is on an anticonvulsant.
• EEG
• More than 50 of patients with epilepsy have
  normal EEG.
• Consider sleep-deprived EEG if resting EEG is
  normal and suspicion is still high.

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Back to Clinical Evaluation

• MRI
• Head CT can be used if suspect mass lesion,
  hemorrhage, or large stroke. Also used if MRI is
  contraindicated.
• Consider
• Lumbar pucture
• Holter monitoring and/or other cardiac evaluation
• Neurology consult

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Back to C. Brown

• Physical exam was normal.
• Chem 7, Ca, Mg, CBC with differential, toxicology
  screens were done. Positive for cannibanoids.
• Resting EEG was normal.
• Telemetry monitoring normal.
• Echocardiogram and carotid Doppler duplex normal.
• Follow up with me as outpatient.

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Back to C. Brown

• Neurology referral made.
• Made it clear to patient that he cannot drive,
  swim, take a bath, or operate heavy equipment.
• Several days later, received call that had two
  more similar episodes witnessed by mother.
• Phone interviewed mothervirtually identical
  behavior, BUT she notes a more postictal state
  confused for several minutes after event.

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Back to C. Brown

• Scheduled outpatient MRI and outpatient sleep
  deprived EEG.
• Curbsided neurologist to see if medication needed
  to be started.

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Seizure Management - Medication

• When to start medication? Definitely start if
• there is a structural lesion, such as tumor, AV
  malformation, infection
• EEG with a definite epileptic pattern
• history of brain injury or stroke, CNS infection,
  significant head trauma
• Todds postictal paresis
• Status epilepticus on presentation
• Otherwise, get neurology consult.

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Seizure Management - Medication

• Most common medications used are phenytoin,
  valproate, and carbamazepine.
• Each neurologist seems to have his/her drug of
  preference.
• For absence seizure, ethosuximide is clearly the
  drug of choice.

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Seizure Management - Medication

• Although not proven in controlled studies, it is
  still believed that monotherapy is advantageous.
• Can use Swedish Online Pharmacology or Epocrates
  to establish dosing, side effects, and monitoring
  guidelines.
• As always, be aware of drug-drug interactions,
  metabolism in the elderly, and non-compliance due
  to side effects.

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Seizure Management - Medication

• Monitoring AED levels most helpful when patient
  is doing well and when s/he is symptomatic.
• Generally, at the outset need to monitor
  regularly consider weekly. Once benchmark
  blood level obtained, can then monitor annually
  as long as no breakthrough seizures.

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Seizure Management - Medication

• Stopping medication should be weighed against
  newer studies showing 20-30 recurrence. General
  rule of thumb has been seizure free for 2 years.
  
• If stopping medication, must be a slow taper over
  months.

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Seizure Management - Medication

• NEW MEDICATION
• Felbamate
• Gabapentin
• Lamotrigine
• Topiramate
• Tiagabine
• Levetiracetam
• Oxcarbazepine
• Zonisamide

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Seizure Management Nonpharmacologic

• Vagus Nerve Stimulation
• Epilepsy Surgery

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Back to C. Brown

• Spoke with neurologists partner who agreed with
  outpatient workup and starting patient on ½
  maintenance dose of valproate (usual maintenance
  dose is 15 mg/kg/d).

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Back to C. Brown

• Charlie sees the neurologist, has had another two
  brief lt 5 second episodes in the interim, this
  time just with drooling. Confused?
• However, Charlie tells the neurologist that he
  NEVER had a postictal state.
• Neurologist thinks he needs a cardiac workup and
  recommends a colleague.

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Back to C. Brown

• Curbsided cardiologist who is very confused
• In the meantime, get MRI results back. There is
  a linear area of increased signal in
  periventricular white matter of the left temporal
  lobe suggestive of old ischemia or gliosis.

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Back to C. Brown

• Mother reports to neurologist her sons previous
  episodes and confirms that there was a postictal
  period.
• Neurologist calls me back telling me he will see
  Charlie again and this time probably start him on
  medication.
• Cheers all the way around for the team effort!