CNS Module: Exam 2 > Seizures > Flashcards

Seizures Flashcards

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1
Q

Seizure Definition

A

isolated clinical event, transient

–> abnormal electrical brain activity

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2
Q

What define a provoked seizure?

A
  • medications (bupropion, tramadol)
  • substance use/withdrawal (alcohol use disorder)
  • metabolic factors (anorexia)
  • acute brain injury
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3
Q

What define an unprovoked seizure?

A
  • idiopathic
  • epileptic
  • remote symptomatic (secondary to something at least 7 days old)
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4
Q

Epilepsy Definition

A
  • chronic disorder

- 2+ unprovoked seizures at least 24+ hours apart

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5
Q

What is a reflex seizure?

A

Epileptic event secondary to some stimuli (motor, cognitive, or sensory)

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6
Q

Which medications are associated with seizure?

A
  • bupropion
  • antipsychotics
  • stimulants (amphetamines, cocaine)
  • lithium
  • some opioids (tramadol, merperidine)
  • varenicline
  • some antibiotics (carbapenems, quinolones)
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7
Q

What happens in the brain?

A

imbalance between excitatory (glutamate) and inhibitory (GABA) actions of the brain

TOO much excitatory, too little inhibitory

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8
Q

Tonic Seizure Definition:

A

stiffness

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9
Q

Clonic Seizure Definition:

A

convuslsions/jerk

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10
Q

myoclonic Seizure Definition:

A

muscle jerk/short twitches

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11
Q

Atonic Seizure Definition:

A

relaxed/limp

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12
Q

Tonic-Clonic Seizure Definition:

A

stiffness followed by convulsions

Gran-Mal seizure

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13
Q

Absence Seizure Definition:

A

loss/regain consciousness for a brief period

Petite-Mal Seizure

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14
Q

Types of seizures: focal/partial

A

originate in one hemisphere

  • simple partial: remain conscious
  • complex partial: unocnscious or impaired awareness/responsiveness

(may experience motor or non-motor symptoms)

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15
Q

Types of seizures: Generalized

A

both hemispheres
AND
loss of consciousness

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16
Q

Types of seizures: Status Epilepticus

A

5+ minutes of seizure activity
OR
recurrent seizures without return to baseline between seizures

(this can be any seizure)

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17
Q

Risk Factors

A
  • family history
  • prolonged lack of sleep
  • alcohol/drug misuse
  • prescription medications
  • metabolic issues (hypo/hyperCa, hypoglycemia, hypoNa)
  • complications during pregnancy/delivery
  • traumatic brain injury (concussion)
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18
Q

What is needed for a diagnosis?

A
  • physical exam
  • detailed history from pt or witness of sx
  • complete neurological exam
  • medication hx
  • Labs (BAC, tox screen, pregnancy)
  • EEG & brain imaging
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19
Q

Seizure first aid:

A
  1. assess the situation
  2. get pt to ground c/ something under their head
  3. recovery position!
  4. remove glasses/ things that could constrict their neck
  5. TIME (no improvement in 5 mins = 911)
  • DO NOT:
  • prevent pt from moving
  • put something in their mouth
  • let them drink/eat until fully alert
  • DO:
  • stay with pt until EMS arrives
  • be comforting (they can be conscious!)
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20
Q

When is a patient at extra risk?

A
  • pregnancy
  • being in water
  • unable to wake after seizure
  • aggressiveness
  • PMH DM
  • more than 1 seizure in a row
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21
Q

When are they hospitalized?

A
  • recurrent seizures
  • seizure secondary to infection, injury, or tox
  • seizure + fever
  • loss of consciousness
  • lack of social support @ home

these pts are always seen/ managed by NEUROLOGY

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22
Q

What is classified as an Acute Seizure?

A

lasting < 2 mins; no pharm intervention necessary

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23
Q

Tx: Acute Seizure Management

A

IF tx needed: BENZOS (IV)
- lorazepam: fast acting, short lasting (repeat q5-10m prn)

  • EMS situation: IM midazolam (can be effective)
  • recurrent seizure: rectal diazepam (can be effective)
  • advanced case: intranasal benzo
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24
Q

What is the key thing we need to remember with Status Epilepticus?

Study These Flashcards
A

MAINTAIN an AIRWAY
DO NOT give paralytic agents

Medical emergency

25
Tx: Status Epilepticus
Initial: IV short acting benzos (lorazepam) - may use alt route if no IV access (IM midazolam is backup) Follow up: reduce risk of relapse with long-acting anti-seizure med remember: correct potential nutritional causes - IV glucose if hypoglycemic (< 70) - IV thiamine (alcohol use disorder)...banana bag
26
So what meds do we want to use with status epilepticus?
- VPA - phenytoin - fosphenytoin - continuous infusion of midazolam - phenobarbital - levetiracetam LONG ACTING ANTI-SEIZURE MEDS
27
When do we start Chronic Seizure Management?
after evaluation & diagnosis by neurologist (first-time seizure is not always indication to start tx) - meds usually started after 2nd UNPROVOKED or REFLEX seizure (or status epilepticus) WANT MONO TX
28
First line tx options for: partial/focal
- carbamazepine - lamotrigine - keppra - oxcarbazepine - topamax - zonisamide
29
First line tx options for: generalized tonic-clonic
- lamotrigine - levetiracetam - VPA - topamax - zonisamide
30
First line tx options for: abscense
- ethosuximide | - VPA
31
First line tx options for: myoclonic, atonic, atypical
- ethosuximide - lamotrigine - levetiracetam - VPA
32
ADR of interest
- pregnancy: teratogenic - dizziness: fall risk - mental status changes: evaluate thoughts of harm @ each visit - incr. risk of osteoporosis
33
Carbamazepine 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range
1. partial/focal, generalized tonic-clonic 2. SJS/TEN, aplastic anemia and agranulocytosis - HLA-B*1502 allele (Asian ancestry) 3. PMH bone marrow suppression, hypersensitivity to TCAs, use w/i 14d of MAOi - avoid in pregnancy (spina bifida, developmental disorders & congenital abnormalities) 4. slow PO uptake (present 3-4 hrs after dose) 5. 4 - 12 mcg/mL
34
ADR: Carbamazepine
- dizzyness/headache - upset stomach/constipation - change in appetite - hypoNa (monitor @ baseline, 1 mo later, periodically)
35
Oxcarbazepine 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range
1. partial/focal ONLY - very similar to carbamazapine 4. weak inducer of CYP 3A4 (carbamaz is strong) - decr. concentrations of PO contraceptives (need additional form of non-hormone contraception)
36
Levetiracetam 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. partial, myoclonic, generalized tonic-clonic * adjunctive agent 3. no sig. CI or drug interactions 4. monitor CNS issues 6. monitoring serum levels not recommended
37
Levetiracetam ADR
- upset stomach - dizzy - asthenia - irritability more alert? (reported) low chance of SJS / TEN
38
VPA/DVP 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. complex partial, generalized absence * monotx or adjunctive 2. hepatotoxicity (mostly 1st 6 mo), pancreatitis, teratogenic (neural tube defects/other malformations) 3. hepatic disease/dysfunction - CYP inhibitor 4. depakene=IR; depakote=ER (mania secondary to bipolar, migraine prophylax) 5. 50 - 100 mcg/mL (trough levels w/i 3-4 days of starting/adjusting the dose) 6. monitor LFTs at baseline & frequently in 1st 6 mo - watch baseline CBC & periodically after DO NOT change mnfct/prod. --> incr seizure risk
39
ADR VPA/DVP
- alopecia - wt gain - V/D - upset stomach (help when taken c food) - dose related thrombocytopenia - asthenia - tremor (worsen c anxiety or caffeine) DO NOT use in pregnancy
40
Lamotrigine 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. ADJUVANT tx: partial-onset, generalized tonic-clonic, Lennox-Gastaut Syndrome - can be 2nd line monotx in partial-onset seizures - bipolar disorder 2. SJS / TEN - any rash, pt should d/c drug - exacerbated by: VPA, starting above recommended dose or incr. too quickly 3. no CI, just watch VPA c lamictal --> inhibits lamictal metabolism (smaller doses necessary) 4. may cause prolonged ventricular contraction - avoid if: heart block, ischemia, heart failure, structural heart disease 6. liver & renal funct. tests & CBC, other anti-seizure med levels (do NOT monitor lamictal)
41
ADR Lamotrigine
- N - upset stomach - dizzy - blurry vision - dose-related rash (d/c immediately)
42
Lamotrigine dosing
starter packs for 1st 5 wks blue = low dose - VPA orange = normal dose - no meds under blue OR green green = high dose - carbamazepine - phenytoin - phenobarbital - primidone
43
Phenytoin 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. complex partial, generalized tonic-clonic, prevention/tx during/ following neurosurgery - potent inducer; highly protein bound 2. IV formulation: no > 50 mg/min OR 1-3 mg/kg/min in pediatric pts --> hypotension & arrhythmia 3. IV form: sinus bradycardia, 2/3 degree heart block 4. separate from antacid/dairy by 1 hour; ETOH decr levels 5. 10-20 mg/L - steady state 5-10 d 6. CBC, CMP, albumin, VitD * may make absence or myoclonic seizures worse
44
ADR phenytoin
- low grade tremor - der. coordination - confusion - speech issues - trouble concentrating - gingival hypertrophy
45
Above what level can phenytoin actually cause seizures?
30 mg/L
46
What would happen to phenytoin levels with a low albumin (<3.5 g/dL)? How do we calculate phenytoin?
higher FREE phenytoin levels (highly protein bound!!) phenytoin level = lab level/ [(0.2 x alb) + 0.1]
47
Phenobarbital 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. partial, generalized tonic-clonic, status epilepticus 3. severe hepatic disease - -> caution: PMH substance use disorder (GABA agonist) * AVOID in PREGNANCY (cognitive effects) 4. potent CYP inDucer 6. CBC, CMP (ONLY if AE present)
48
ADR Phenobarbital
- agitation - confusion - constipation - hallucinations - mood changes
49
Ethosuximide 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range 6. monitoring
1. ABSENCE only 5. 40-100 mcg/mL 6. CBC, LFTs, trough level prn
50
ADR Ethosuximide
- upset stomach - mood change - headache - N/V - psychosis - SJS, aplastic anemia, agranulocytosis (possible, but rare)
51
Topamax 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range
1. partial, generalized tonic-clonic (monotx or adjunct) - migraine prevention, wt loss, nerve-based pn (also used) 4. DO NOT use c PREGNANCY (cleft lip/plate)
52
ADR Topamax
- dizzy - confusion - kidney stones - wt LOSS (take HS to decr. AE)
53
Zonisamide 1. indication: 2. BBW? 3. CI: 4. *: 5. reference range
1. focal IF 16+ yo (adjunct) | 3. sulfonamide allergy
54
ADR Zonisamide
- agitation - confusion - fatigue - nausea - kidney stones
55
How/When do we switch seizure meds?
1. make sure they were on the right: dose, level, amt of time 2. verify AE present that is dangerous or (-) impact QoL 3. do not make a hard change 4. counsel pts to be adherent & follow instructions (can take time (months) to get right!)
56
Are there non-pharm options?
YES - surgery (really great if drug-resistant, usually caused by tumors) - laser tx - vagal nerve stimulation - direct brain stimulation
57
Seizure + Pregnancy Tips
- verify pregnancy status EVERY visit - no "perfectly safe" anti-seizure med - use folic acid prior to pregnany - DO NOT use VPA - if cont. tx --> check levels regularly - counsel on effective birth control methods (if pt does not want to get pregnant) bc some COC are effected
58
Seizure + Driving Tips
seizure free for a set period of time before being allowed to drive - 6 mo in PA usually need documentation by physician
CNS Module: Exam 2
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