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Seizures for Test 2
K Wolz from podcast
| Question | Answer |
|---|---|
| What is the definition of Seizure? | An epileptic seizure is a transient recurring event of altered brain function caused by relatively abrupt abnormal or excessive electrical discharges from brain cells. |
| What is the most important thing to remember about the definition of Seizure? | In seizure activity, the electrical conduction is either sped up or slowed down. |
| What is the definition of Epilepsy? | Epilepsy is a chronic brain disorder of various etiologies characterized by recurrent unprovoked seizures. |
| If the electrical activity in a seizure is sped up, what is observed? | A grand mal or generalized seizure |
| If the electrical activity in a seizure is slowed down, what is observed? | The patient "going away," very slow to process information, etc. |
| Define Aura. | A subjective disturbance of perception that represents the start of certain seizures. It actually represents a focal electrical disturbance at the start of a seizure. |
| What is dejavu? | An out of body sensation. |
| What is significant about the aura in a seizure? | It is the only portion of the seizure that the patient actually remembers. |
| Because epilepsy has a negative connotation related to mental illness, what do you see charted in history instead? | "Recurrent seizure activity" |
| What close together must the first and second seizure be for a diagnosis of epilepsy? | It doesn't matter. It can be decades apart. A second seizure in a lifetime is diagnostic for epilepsy. |
| What is the significance of "aura" in an epileptic patient? | It can serve as a warning of the onset of a seizure. |
| What are other types of warning symptoms that patients may experience before a seizure? | Patient's may get a headache, become tired or lethargic, may have an unusual smell or see a flash of light. |
| How common is it for patients to experience a warning symptom before a seizure? | Very UNcommon. It only happens in a small percentage of patients. |
| What time of life is Absence and Myoclonic seizures onset? | Childhood |
| What time of life is Generalized Tonic-Clonic and partial seizures onset common? | Throughout life |
| When is the rate of all seizure types highest? | At the beginning and end of life. |
| Why is the time of life when the rate of all seizure types highest logical? | Because at the beginning of life, we are looking at an immature nervous system. At the end of life, we are looking at an insulted, decompensated, or injured nervous system. |
| When evaluating the patient, what must be ruled out with a seizure? | An organic cause, ie. electrolyte imbalance, meningitis, encephalitis, diabetes, etc. |
| Was there the presence of any prodromal symptoms? If so, what might some be? | If yes, could be headache, fever, chronic illness or complaint. |
| Why is it so important to have a description of the seizure from a reliable source? | Because so much of the diagnostics of the disease is based on what is seen by someone who is reliable. That information helps the physician pinpoint which part of the brain is responsible for initiating the seizure. |
| What are some of symptoms patients may report "post-ictally" (after a seizure)? | Confused, lethargic, difficult to arouse, and having safety issues related to nursing care. |
| What is significant medical history for seizures? | Febrile convulsions, head injury, cerebrovascular or cardiovascular disease (rarely), cancer, substance abuse - cocaine, infectious disease - cystisercosis. |
| What is cystisercosis? | It is a worm, a parasite. It comes from meat that is undercooked or poorly processed. |
| Why do we ask a patient with neurological symptoms if they have traveled outside the country? | Due to the prevalence of cystisercosis outside the US. |
| How does the ingested parasite cause neurological effects? | It enters the body through the ingestion of bad meat, enters the bloodstream through the stomach, enters the brain from the bloodstream, and in the brain it builds a "house". |
| Why is the parasite's "house" detrimental? | The "house" causes increased intracranial pressure. |
| What is family history data significant for seizures? | Family history of seizures, or family history of other neurological disorder, like Tourette's, Parkinson's, Alzheimer's. |
| What is significant social history for seizures? | Alcohol use, illicit drug use, travel |
| Why is alcohol use significant? | Alcohol LOVES the brain. If the brain is accustomed to a certain level of alcohol all of the time and the patient is unable to sneak a drink at work, they are at risk for a grand mal seizure. |
| Which drugs place the patient at risk for a seizure? | Methamphetamine, cocaine, even prescription drugs that alter the biochemistry of the brain, like psych drugs. |
| Why can't a patient who has had a seizure take Ziban? | Because Ziban(Wellbutrin)inhibits the reuptake of serotonin, it changes the biochemistry of the brain. Changing the biochemistry of the brain places the patient at risk for seizures, which is contraindicated in a patient with seizure history. |
| The physical exam includes close neurological and cardiovascular exams and Lab and imaging studies. Why? | To rule out an organic cause of the seizure. |
| What types of labs are done to rule out an organic cause of seizure? | Tox screen, alcohol level, electrolytes, Calcium, Magnesium, Glucose, Creatinine, BUN and CBC. This is ruling out heavy metal poisoning, drug abuse, etc. |
| What type of electrolyte imbalances are we concerned with in seizures? | Hypernatremia, Hypocalcemia, hypoglycemia, Severe hypomagnesia |
| How does a magnesium imbalance predispose a patient to seizure? | Because magnesium is responsible for preventing vasospasms, the patient could have a vasospasm, which causes some hypoxia. The hypoxia could then cause a predisposition to a seizure. |
| What labs and/or conditions release toxins in the body and could result in a seizure? | Creatinine, BUN, Sodium levels between 110-115, Hepatic issues, like Hepatic encephalopathy, anemias, infections, etc. |
| Before determining a neurological cause in a patient with a seizure, what must be done? | Rule out underlying causes |
| Abuse of what drug could result in a Sodium level between 110-115? | Lasix |
| Why might a patient take too much Lasix? | An elderly patient might experience weight loss, disease pathology, aging, underlying renal or hepatic issues and can no longer tolerate their prescribed dose of Lasix. |
| When a patient presents to the ER having had a seizure from taking too much Lasix, what actually caused the seizure? | An electrolyte imbalance. |
| Which electrolyte is imbalanced in a high dose of Lasix? Is the electrolyte too high or too low? | Sodium, too low (110-115) |
| What is the most prominent cause of seizures in a patient with a history of seizures? | Anticonvulsant levels: They forget to take it, or stop their meds, etc. |
| What tests would be conducted if an infection is suspected? | Lumbar puncture, CT/MRI, EEG |
| What do the results of the EEG dictate? | If abnormal, they will prescribe medications. If normal, they may wait and see what happens. Especially if they only have one seizure. |
| What is important to know about EEGs in infants? | They are ALWAYS abnormal. (Probably, abnormally normal.) |
| Why would an infants EEG always be abnormal? | Because of their immature nervous system. |
| What is the most common cause of epilepsy before the age of 20? | Idiopathic - Or cause of unknown origin. |
| What is RARELY the cause of epilepsy over the age of 30? | Idiopathic - Or cause of unknown origin. |
| Highest incidence of age of onset is under 5 yrs and over 65 years old. Why? | Because an immature nervous system responds the same as in insulted, injured or decompensating nervous system. |
| What is the significance of age on seizures? | Age effects the etiology of seizures. |
| What is a common etiology in infants and children? Give examples. | Perinatal injury, like low APGAR scores, decelerations, low fetal heart rate, placenta previa, plactenta abruptia, premature birth, metabolic disorders (Tay Sachs, Downs, Trisomies)malformation, infection (sepsis, meningitis), Trauma |
| The more premature the infant is at birth the greater the risk of what? | Hypoxic episode |
| Hypoxic episodes during birth increases the risk for what? | Seizures |
| What does the hypoxia cause in the infant? | An anoxic hot spot or seizure threshhold |
| What is the significance of an anoxic hot spot? | It's like a silent bomb. It's just sitting there not bothering anything, but the first time the child performs a function that uses that part of the brain, it causes a seizure. |
| Who has anoxic hot spots? | Everyone |
| What is the value of seizure threshhold? | It varies per person, like host factors. |
| What two things will lower your seizure thresh hold and increase the potential to have a seizure? | Fatigue and Stress |
| Excessive lack of sleep can cause what? | Psychological collapse, seizure |
| What does the treatment for seizure depend on? | Whether or not the patient has an underlying cause |
| Why might a pre-pubescent growth spurt trigger a seizure? | Because the brain is trying to figure out how to connect itself and it is triggering all sorts of synapses at the same time. Unfortunately, it may trigger the one that causes a seizure. |
| What are common etiologies for seizure in adults? | Vascular disease (anyeurism, AVM), brain tumor, idiopathic, metabolic defects (diabetes, encephalopathy, renal issue, lupus), infection, drug/alcohol use, trauma |
| All patients who experience significant head trauma are put on what type of medication prophylactically? | Anticonvulsants |
| How long do they usually stay on Anticonvulsants prophylactically after a significant head trauma? | 1 year (The neuro magic #...hee hee:) |
| What are conditions that MIMIC seisures, but are NOT seizures? | Syncope, psychogenis pseudoseizures, panic/anxity/hyperventilation attacks, movement disorders (Alzheimers, dementia, Parkinsons), sleep disorders (narcolepsy), hypoglycemia, TIAs, migraines |
| What happens in syncope? | There is a vasovagal effect. They decrease oxygen perfusion to their brain and they become hypotensive. When the brain is REperfused, they sometimes have a little bit of seizure activity. |
| What type of observations are seen in the seizure activity associated with syncope? | NOT grand mal type seizure activity. More like trembling, some shaking of the limbs, rolling of the eyes, |
| The BIG part of the definition for seizure is what? | CONSISTENT, REPETITIVE BEHAVIOR!! |
| What is the difference between a tremor and a seizure? | If it stops, it's a tremor. If it continues, it's seizure disorder. |
| Give examples of "Consistent, Repetitive behavior" - Seizure. | My face gets numb 4x/day and lasts 20 seconds; my tongue moves in and out of my mouth very quickly, my eyes move up to the left and jerk, or a tick. |
| What is the most common type of seizure? | Grand mal seizure ("large bad") |
| What is the other name for a Grand mal seizure? | Tonic clonic seizure |
| How many phases of a seizure are there? Describe the first one. | Two phases: 1)Tonic phase:the pt initially loses consciousness & falls if standing (loss of postural tone); tonic muscle spasms begin and the patient may let out a loud cry or yell due to air being forced past the larynx. |
| Describe the second phase of a seizure. | Clonic phase is a period of generalized, bilateral, repetitive, move, clonic movement. |
| What is another definition of tonic phase of seizure? | A short lived period of muscle rigidity due to continues muscular contractions. |
| What is another definition of clonic phase of seizure? | Follows the tonic phase and is a period of rapid, alternating muscular contraction and relaxation. |
| What is the other name for an Absence seizure? | Petit mal seizure. ("small bad") |
| Define an absence seizure. | Very brief episodes of loss of consciousness (30 seconds) |
| In which patient population do absence seizures occur? | Primarily in children |
| At what stage of life do absence seizures disappear? | Puberty |
| How does Kathy Wolz describe the absence seizure? | "The going away and the coming back!" |
| What is a common misdiagnosis in children with absence seizures? Why? | ADD, because they have no recollection of loss of consciousness. |
| While it isn't important that we DIAGNOSE which type of seizure the patient is having, how do we help the physician make the diagnosis? | By describing exactly what we observe during the seizure. |
| What are classifications of seizures? | Typical (no motor symptoms); Atypical (positive automatisms, motor involvement or autonomic symptoms) |
| What is two types of partial seizures? | Simple (sensory seizure in which a single limb may twitch or pt may have an unusual sensory experience); Complex (consciousness is impaired & pt may exhibit complex automatisms). |
| Give examples of complex automatisms. | Lip smacking, aimless pacing, etc. (Sounds like Alzheimer's, right? That's why you see cross over on the meds!) |
| Give an example of an usual sensory experience. | An unusual odor. |
| What is a feature of a Secondarily Generalized Seizure? | A partial seizure (either simple or complex) may progress to a generalized seizure, ie. started w/leg arm, progressed to left side, now whole body. |
| What are characteristics of a Pseudoseizure? | It is NOT a seizure; usually seen in psychiatric pts or those seeking medical attn; pt is good at mimicking generalized tonic clonic seizure; rarely assoc w/incontinence, tongue biting or other injury. |
| What is true of the characteristics of pseudoseizures from one event to the next? | Patients make different movements from one seizure to the next. |
| What is true of the characteristics of a true seizure from one event to the next? | The presentation of the seizure is always the same! ie. start off with left hang shaking and progress to tonic clonic...that's never going to change! |
| What are 3 most important facts about seizures? | It is a tremor if it stops, a seizure if it continues; Seizures are repetitive and consistent; True seizures always present the same way! |
| What is the primary treatment for seizures? | Medication |
| What is the treatment for a single, isolated seizure? | Could be medication, but usually do not require chronic therapy. We treat the underlying cause: F&E imbalance, hypoglycemic, fever. Repeat seizures are not expected. |
| When we correct a seizure by balancing an imbalanced F&E, achieving normoglycemia or normothermia, what do we do to prevent future seizures? | We don't. Because there was an organic cause for the seizure, we do not expect repeat seizures. |
| What are favorable prognostic indicators? | Childhood onset epilepsy; Longer seizure free interval before drug withdrawal; Primary generalized tonic-clonic seizure; Normal or improved EEG at time of drug withdrawal |
| Why is childhood onset epilepsy a favorable prognostic indicator? | Because the theory is that the nervous system is immature and that as the system matures it will correct whatever the underlying seizure activity is, especially if it is not related to brain damage, trauma, or an underlying pathology. |
| What makes pharmacologic treatment difficult? | Having only one symptom, ie eye, nose OR mouth involvement. The smaller the area involved in the cause of the seizure, the harder it is to find a drug that will be used to treat the area. |
| A generalized tonic clonic seizure involves what part of the brain? | An area large enough to identify and treat. Not a specific area, but a treatable one. |
| What are unfavorable prognostic indicators in seizure? | Adult onset epilepsy; Freq, severe seizures B4 remission;Partial seizures; EEG abnormalities at time of drug w/d; Abrupt w/d of benzo's or barbituate antiepileptic drugs; Atypical febrile seizure; |
| Why is adult onset epilepsy an unfavorable prognostic indicator? | Becuz the seizure occurs in a mature nervous system, somewhere along the line there had to be an injury, insult or underlying cond & if there is an irritable part of an adult brain, there isn't the ability to reroute the impulses like there is in a child. |
| Why are partial seizures an unfavorable prognostic indicator? | Because they involve a small symptom, like sniffing, or tongue protrusion, which is brought on by a small part of the brain that is difficult to treat. |
| Why is compliance a problem with anti-seizure drugs? | Because patients don't like the way the medications made them feel. There are HORRIBLE side effects. |
| What is a complication of noncompliance with anti-seizure drugs? | The more a patient takes themselves off and then gets put back on medication, the less the chance of good control, and the higher the chance of having to stay on the drugs for the rest of your life! |
| With Partial Seizures, like: If my seizure activity is that I sniff 5,000x a day, but I DON'T KNOW that I'm doing it, it doesn't bother ME. It bothers the people around me. How does that effect compliance? | Well, the seizure didn't bother the patient, but the side effects of the drugs REALLY BOTHER the pt, so they are NONCOMPLIANT! |
| What are some side effects? | Confusion, lethargy, unusual hair growth, |
| Why is abrupt withdrawal from Benzodiazepines or Barbiturates Antiepileptic drugs an unfavorable prognostic? | Because it increases the risk of seizures due to abrupt change in the biochemistry of the brain. |
| How are doses of antiepileptic drugs determined? | Doses are continually titrated up until there is therapeutic success (or failure) allowing adequate time between seizures |
| How do doses of antiepileptic drugs effect side effects? | The higher the dose of medication, the greater the chance of unfavorable side effects. |
| How do physicians determine the medication to use? | Medication is determined based on the seizure type and the side effect profile. |
| Why is monotherapy preferred? | The lowest dose of a single drug is preferred to minimize toxicities of therapy with (AED) antiepileptic drugs |
| What is a Ketogenic Diet? | It is a High Fat diet and is used by epileptic patients with some success, especially in pediatric patients. |
| What must be done before any AED therapy is initiated? | Baseline labs, because of the toxicity of the drugs. |
| What are the most important labs to be checked in advance of AED therapy? Why? | Liver function tests, because most drugs are metabolized in the liver and excreted through the kidneys. |
| What effect do the AEDs have on Liver Function Tests? | They elevate liver enzymes. |
| What is the protocol for lab tests in AED taking patients? | Must do liver function tests every 3 months at least. |
| What are some benefits of monotherapy? | Greater advantage for patient due to fewer adverse effects, improved compliance, fewer drug interactions, and lower cost. |
| What is the dosing start and titration schedule? | Start with dose at lower end of quoted "population" range; obtain serum AED level at steady state (3 half lives); adjust dose based on levels & pts response. |
| What two things are looked at when an AED blood level is checked? | Therapeutic blood level and How the patient FEELS!! |
| What defines therapeutic success? | Optimal seizure control with minimal or tolerable side effects. |
| When therapeutic success is achieved, what is the continued treatment protocol? | Continue with current AED regimen and monitor periodically for continued efficacy and toxicity. |
| Define Therapeutic Failure. | Suboptimal seizure control or intolerable side effects. |
| What factors interfere with the ability to label a patient with Therapeutic Failure? | Non compliance with the drug regimen is most common; inadequate dose and/or duration of therapy; new or progressive neurological disorders; misdiagnosis of seizure type & selection of wrong AED. |
| What is the next step when there is Therapeutic Failure? | Begin a trial with another AED; Do not taper the first AED; After the new AED is in therapeutic range, then you can withdraw the first AED (Like Heparin & Coumadin) |
| What is the risk if you take the patient off the non-Therapeutic AED before the patient reaches a therapeutic blood level on the new AED? | Risk for increased or recurrent seizure activity. |
Created by:
Kitty Groebli
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