4. DEFINITION
⢠Seizure is a sudden, involuntary, time-limited alteration in behavior
accompanied by an abnormal , synchronized electrical discharge of
cortical neurons.
⢠The Alteration in behavior may involve a change:
⢠Motor activity
⢠Autonomic function
⢠Consciousness
⢠Sensation
5.
6. STATUS EPILEPTICUS
⢠Status epilepticus: is defined as:
More than 30 minutes of continuous seizure activity or
Two or more sequential seizures without recovery of consciousness
between seizures.
9. WHO
⢠World Health Organization (WHO) estimates that 50 million people of
all ages are affected by epilepsy worldwide with more than 85% living
in the developing world.
⢠In developing countries, up to 90% of epileptic patients may not
receive the treatment they require and this wide treatment gap remains
a reason for tremendous individual, family, social and economic
burden.
10. EPIDEMIOLOGY IN SAUDI ARABIA (2001)
⢠Prevalence rate (PR) for active epilepsy was 6.54 /1000 population.
⢠28% of the patients had partial seizures,
⢠21% generalized seizures and in
⢠51%, it was not possible to determine if the generalized seizures had focal onset or not.
⢠The epilepsy was symptomatic in 32% of the cases:
⢠Perinatal encephalopathy 23%,
⢠Head injury 4%,
⢠Childhood neurological infection 4%
⢠Stroke 1%.
⢠Febrile convulsions PR was 3.55 /1000 children under the age of 6 years
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11. CONTINUE
⢠The rate of mortality from status epilepticus (defined
as death within 30 days of status epilepticus) is 22%.
⢠Mortality rate among children is 3 percent.
⢠Mortality rate among adults is 26 percent.
⢠Mortality rate in elderly is 38 percent.The highest
12. EPILEPSY STATISTICS
⢠One in 20 people will have a one-off epileptic seizure at some point in their life
(although this does not necessarily mean that they have epilepsy).
⢠One in 50 people will have epilepsy at some time in their life (not everyone with
epilepsy will have it for life).
⢠Around 87 people are diagnosed with epilepsy every day.
⢠There are around 60 million people with epilepsy in the world.
⢠Up to 3% of people with epilepsy will be affected by flashing lights (called
photosensitive epilepsy), so most people with epilepsy do not have seizures
triggered by flashing lights.
13. PEAKS
⢠The incidence varies greatly with age, with high rates occurring in early childhood ,
falling to low levels in early adult life, but with a second peak in those aged over 65
years.
16. SEIZURES CLASSIFICATION (OLD)
⢠Partial: in start and involve part of the brain
⢠Simple: without impair of awareness
⢠Complex: with impaired awareness
⢠Generalized: bilateral abnormal electrical activity with bilateral motor
manifestation with impaired conscious
⢠Absence (Petit mal)
⢠Tonic
⢠Myoclonic
⢠Tonic-clonic (grand mal)
⢠Akinetic
⢠Unclassifiable: seizure that donât fit with any class
Awareness
17.
18.
19.
20. ANATOMICAL SITE
⢠Most of seizures begin in the
temporal lobe.
⢠Most temporal lobe seizures begin
in the mesial temporal lobe
structures.
⢠The frontal lobe is the next most
frequent site for CPS.
26. PATHOPHYSIOLOGY
A seizure results from a paroxysmal high-frequency or
synchronous low-frequency electrical discharge that can arise
from almost any part of the cerebral cortex (i.e., Not the
cerebellum, brainstem, or spinal cord).
27. CONTINUE
Based on experimental models of epilepsy, the event is
thought to involve a reduction in cortical inhibition mediated
by GABA, combined with divergent excitation, probably
mediated by glutamate.
28. CONTINUE
In a partial seizure, the synchronously depolarizing neurons
remain localized, while in a generalized seizure, the
synchronous depolarizations are present throughout both
hemispheres.
47. HISTORY
⢠Preictal
⢠Any warning? Abdominal pain, fear, unpleasant sensation
⢠What was patient doing
⢠Asleep or awake
⢠Triggers
48. ⢠⢠Ictal
⢠Consciousness?
⢠Repetitive behaviors during spell â lip smacking, etc
⢠Body movements â part or all
⢠Cyanosis
⢠Incontinence
⢠How long, how many, how often
⢠Gaze deviation, eye rolling
49. ⢠Post ictal
⢠How did patient feel after (Drowsy? Confused? Tired?)
⢠How long until return to baseline?
⢠Trauma
52. WHEN TO START TREATMENT?
⢠People should be treated with A.E.D when the clinician
thinks that the person will probably have another seizure
without treatment.
⢠The seizure type or syndrome may help with this decision.
⢠For example, absence seizures are rarely isolated and so
require therapy, whereas febrile seizures are often isolated
and therapy is not indicated.
53. IN THESE CASES, IT IS REASONABLE TO
BEGIN A.E.D.
⢠Seizure recurrence is more likely if the patient has:
⢠Focal neurologic deficits
⢠Mental retardation
⢠EEG that demonstrates epileptiform abnormalities
⢠Structural brain lesion.
54. CONTINUE
⢠In patients with a well-defined provocative etiology, it
is best to treat the underlying process rather than the
seizures themselves.
55. NON-PHARMACOLOGICAL:
⢠Lifestyle modification
⢠Adequate sleep.
⢠Healthy diet.
⢠Avoidance of alcohol, stimulants, etc.
⢠Stress reduction.
⢠Ketogenic diet: high in fat and low in CHO
⢠Vagus nerve stimulation
⢠Implantable neurostimulation: Used when antiepileptic treatment have failed
⢠Surgery: It is a standard treatment for patients with partial seizures that are resistant to
medication.
⢠Anterior temporal lobectomy
⢠Amygdalohippocampectomy
⢠Laser therapy
56. PHARMACOLOGICAL
⢠To start pharmacological therapy consider the following:
⢠Start monotherapy
⢠Start low dose and slowly increase until resolve of seizure attacks
⢠Discontinuation of medication can be consider if more than 2-5
years seizure free
⢠Add second medication if the first medication partially effective or
significant side effect from first medication
57. TREATMENT
⢠Partial Seizure:
⢠First Line: Carbamazepine or Lamotrigine.
⢠Not tolerated: Levetiracetam, Oxcarbazepine, or Sodium valproate.
59. TREATMENT
⢠Absence seizures (non motor):
⢠First line: Ethosuximide or Sodium valproate.
⢠Not tolerated: Combination of Ethosuximide, Lamotrigine or Sodium
valproate.
60.
61. STATUS EPILEPTICUS
MEDICAL EMERGENCY
⢠Once the diagnosis of status epilepticus is made, treatment should be initiated
immediately.
⢠Two or more sequential seizures without full recovery of consciousness between seizures, or more
than 30 minutes of continuous seizure activity.
⢠The goal of treatment always should be immediate diagnosis and termination of
seizures.
⢠The first step in managing status epilepticus is assessing the patientâs airway and
oxygenation.
⢠Start the protocol for management of status epilepticus
62.
63. PROTOCOL FOR MANAGEMENT OF STATUS
EPILEPTICUS (1)
⢠At: zero minutes:
⢠Initiate general systemic support of the airway (insert nasal airway or intubate if
needed)
⢠Check blood pressure.
⢠Begin nasal oxygen.
⢠Monitor ECG and respiration.
⢠Check temperature frequently.
⢠Obtain quick history from relatives.
⢠Perform neurologic examination.
64. PROTOCOL FOR MANAGEMENT OF STATUS
EPILEPTICUS (2)
⢠Lab:
⢠Electrolytes,
⢠glucose level,
⢠complete blood cell count,
⢠toxic drug screen,
⢠anticonvulsant levels;
⢠check arterial blood gas values.
⢠Start IV line containing isotonic saline at a low infusion rate.
⢠Inject 50 mL of 50 percent glucose IV and 100 mg of thiamine IV or IM.
⢠Call EEG laboratory to start recording as soon as feasible.
65. PROTOCOL FOR MANAGEMENT OF STATUS
EPILEPTICUS (3)
o Administer
ď§ Lorazepam (Ativan) at 0.1 per kg IV (2 mg per minute);
o If seizures persist,
ď§ Fosphenytoin (Cerebyx) at 18 mg per kg IV (150 mg per minute).
o At: 20 to 30 minutes, if seizures persist
ď§ Intubate, insert bladder catheter, start EEG recording, check temperature.
ď§ Administer phenobarbital in a loading dose of 20 mg per kg IV (100 mg per minute).
o At: 40 to 60 minutes, if seizures persist
ď§ Begin pentobarbital infusion at 5 mg per kg IV initial dose, then IV push until seizures have stopped, using EEG
monitoring
ď§ Continue pentobarbital infusion at 1 mg per kg per hour; slow infusion rate every four to six hours to determine if
seizures have stopped, with EEG guidance; monitor blood pressure and respiration carefully.
ď§ Support blood pressure with pressors if needed.
68. PREVENTION
⢠Idiopathic epilepsy is not preventable. However, preventive measures can be applied
to the known causes of secondary epilepsy.
⢠Preventing head injury is the most effective way to prevent post-traumatic epilepsy.
⢠Adequate perinatal care can reduce new cases of epilepsy caused by birth injury.
⢠The use of drugs and other methods to lower the body temperature of a feverish child
can reduce the chance of febrile seizures.
⢠Avoid CNS infections
69. TIPS TO PREVENT SEIZURES
⢠Get plenty of sleep each night
⢠Learn stress management and relaxation techniques.
⢠Avoid drugs and alcohol.
⢠Take medications.
⢠Avoid bright, flashing lights and other visual stimuli.
⢠Skip TV and computer time whenever possible.
⢠Avoid playing video games.
⢠Eat a healthy diet.
71. PROGNOSIS
⢠60% of untreated patients have no further seizures during the two years
after their first seizure.
⢠70 % go into remission, defined as being seizure-free for 5 years on or
off treatment.
⢠This leaves 20 to 30 % who develop chronic epilepsy, which is often
treated with multiple antiepileptic drugs.
74. CASE
⢠A 28-year-old woman is brought to the ED by ambulance after she
developed a generalized convulsive seizure at home.
⢠She has had neck stiffness and fever for the past several days and has
been somewhat confused and not âacting like herself.â
⢠The patient is still convulsing when she arrives in the ED 20 minutes
later.
75. CONTINUE
⢠She was started on lorazepam 0.1 mg/kg intravenously (IV)
⢠The patient stops seizing with starting of anticonvulsant therapy.
⢠A lumbar puncture is emergently performed, and analysis of the CSF reveals 9 white
blood cells with a lymphocytic predominance, 32 red blood cells, a protein level of 63
mg/dl, and a glucose level of 65 mg/dl.
⢠An EEG shows sharp wave discharges in the temporal lobes but no electrographic
seizures.
87. MCQ4
⢠What is the first line therapy for the condition in the video?
⢠(a) Carbamazepine
⢠(b) Lamotrigine
⢠(c) Ethosuximide
⢠(d) No need for treatment
89. MCQ5
⢠What is the first line therapy for the condition in the video?
⢠(a) Carbamazepine
⢠(b) Sodium valproate
⢠(c) Ethosuximide
⢠(d) No need for treatment
91. MCQ6
⢠What is the first line therapy for the condition in the video?
⢠(a) Carbamazepine
⢠(b) Sodium valproate
⢠(c) Ethosuximide
⢠(d) No need for treatment
93. ⢠A 23-year-old white female with a generalized seizure disorder is brought into the ED
in status epilepticus.Which one of the following drugs should be administered
initially?
⢠(a) Lorazepam
⢠(b) Fosphenytoin
⢠(c) Pentobarbital
⢠(d) Phenytoin
⢠(e) Phenobarbital
