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Seizures was lectured by Dr. Susan Lippert and translated by Mr. Rattanakvisal Morn during Seminar on Essential Emergency Care Cambodia in May 2012 organized by URC in collaboration with Stanford Emergency International supported by USAID.@rfakhmer @RFI_Km @MJQTVOfficial @ThmeyThmeyMedia • Lecture Objectives • 1. Introduction to seizures • 2. DDX and secondary causes • 3. History and physical • 4. Diagnostic tests • 5. Treatment • 6. Special populations • 7. Precautions • Introduction to Seizures • Definition: occasional, sudden, excessive, rapid electrical discharge within the grey matter of the brain resulting in abnormal neurologic function • Primary Seizures: idiopathic • Secondary Seizures: structural, toxic, metabolic, environmental • CAMBODIA • • Prevalence of primary epilepsy: 5.8 per 1,000 (95% CI 4.6-7.0 per 1,000 in 2011 population survey) • • Secondary seizures much more prevalent • ➢ CNS infection (malaria, Japanese encephalitis, herpes simplex virus, dengue, TB) with seizure is associated with increased morbidity and mortality • • Treatment GAP: nearly 50-80% of people with epilepsy don’t receive systematic treatment or contact health care. • Pathology • Mechanism: the normal anatomic structure or the normal metabolic or biochemical function of neurons becomes disrupted • Abnl fxn → sustained depolarization → ictogenic focus → recruitment of adjacent cells • Classification • 1. Generalized: consciousness lost • 2. Partial (focal): simple or complex; secondary generalization • 3. Unclassified • Status Epilepticus : • Continuous seizure activity for 30 min OR 2+ seizures that occur without full recovery of consciousness between attacks • MORTALITY • • 20% mortality secondary underlying brain injury • • Highest in the elderly with hypoxic/ischemic CNS insult • • Longer seizure continues = more difficult to control • Differential Diagnosis • • Syncope (40-50% have twitching motion) • • TIA/CVA • • Pseudoseizure/ psychogenic • • Extrapyramidal reaction • • Hyperventilation syndrome • Etiologies of Secondary Seizures • Infectious: malaria, Japanese encephalitis, herpes simplex virus, dengue, TB, neurocysticercosis, HIV (meningitis or encephalitis), shigella in children . • Metabolic: glucose, Na, Ca, Mag, renal failure, thyroid • Anatomic: post-traumatic, CVA, AVM, tumors • Toxins: etoh w/d, sympathomimetics, INH overdose • Special populations: pregnancy/eclampsia, febrile seizures, pseudoseizures • History • Character of episode • • Aura • • Duration • • Tongue biting, incontinence • • Tonic-clonic movement • • Post-ictal confusion • Prior seizure history • • Baseline pattern of sz • • Medications • • Sleep deprivation • • Drugs or alcohol • Initial seizure • • Head injury • • Persistent, recurrent headache • • H/o Metabolic or electrolyte abnormalities, cancer, thyroid, anticoagulation • • Alcohol use • Physical Exam • 1. ABC’s; ongoing seizures = status. Evaluate for the presence of ongoing seizure/ status. Airway threatened by obtundation, severe tongue laceration. CAUTION !! Airway control/ paralysis may mask ongoing seizure/status • 2. Evaluate for secondary causes of seizure • • Fevers, hypoxia, hypotension • • Directed neurologic exam for focal deficits • • Search for signs of systemic illness • 3. Evaluate for traumatic injuries • • Head and C-spine injuries; fractures; posterior shoulder dislocations • • Tongue lacerations; Aspiration • Diagnostic Tests • GLUCOSE on all seizure patients • FIRST TIME SEIZURE PATIENTS • Labs: Na, Ca, Mag, electrolytes, BUN, Creat; cbc if suspect infection; Ck if prolonged or blood in urine; urine pregnancy, toxin screen • Imaging: CT. Obtain a CT scan in the following settings: first time seizure, new focal deficits, persistent AMS, coagulopathy, HIV, meningismus, ETOH, change in seizure pattern of epileptic • LP: persistent AMS, suspect SAH or CNS infection Case by case for prior h/o seizure; include medication level if currently taking antiepileptic medications • Overview of Treatment • 1. ABC’s and IV, O2. Airway is at risk. AIRWAY: left lateral decubitus, suction; Intubation using benzodiazepine for induction. • 2. Paralytics may be necessary; CAUTION! Unable to detect continuing seizures clinically. • 3. Diagnose and correct reversible causes of secondary seizures: Reversible causes: Hypoglycemia, hypoxia, electrolyte abnormality, alcohol withdraw, INH overdose (give pyridoxime), severe alcoholism with hypoglycemia/thiamine deficiency. • 4. Pharmacologic therapy • First Aid in Seizures • Apollo Hospitals | First Aid in Seizu...
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