approach to seizure and unconcious patient
TRANSCRIPT
Group – I
Seizure type and frequency History Examination Laboratory findings EEG findings Imaging studies Consciousness
Partial ( focal, local) seizures
◦ Simple Partial Seizures (consciousness not impaired) motor sensory autonomic psychic symptoms
◦ Complex Partial Seizures (consciousness impaired)
◦ Partial seizures with secondary generalization
Generalized seizures
◦ Tonic – clonic seizures (Grand mal)
◦ Absence seizures (Petit mal)
◦ Tonic seizures◦ Atonic seizures◦ Myoclonic seizures
Unclassified seizures
Neonatal seizures Infantile spasms
HISTORY
History obtained◦ Patient◦ witnesses
Describe events ◦ Before◦ During the seizure◦ After
Family history
Personal history
◦ Birth trauma◦ Head injuries◦ h/o febrile seizures◦ CNS infections◦ Middle ear and sinus
infections◦ Alcohol◦ Drug use◦ Earlier auras or
seizures not recognized
Precipitating events
◦ Sleep deprivation◦ Systemic diseases◦ Electrolyte disturbances◦ Metabolic derangements◦ Acute infections◦ Drugs that lower seizure
threshold Β lactam antibiotics Quinolones INH Acyclovir Theophylline
Airway, breathing, circulation – vital signs Signs of infection or systemic illness Neurocutaneous markers
◦Neurofibromatosis◦Tuberous scleroses◦Liver and kidney disease◦Subcutaneous nodules
Organomegaly◦Storage disorders
Limb asymmetry ◦Brain injury early in development
Auscultation of heart and carotid arteries◦Predisposition to cerebrovascular disease
Signs of injury◦ Head injury◦ Tongue, Lip bite◦ Fractures and soft
tissue injury
The Differential Diagnosis of SeizuresSyncope Vasovagal syncope Cardiac arrhythmia Orthostatic hypotensionPsychological disorders Psychogenic seizure Hyperventilation Panic attackMetabolic disturbances Alcoholic blackouts Delirium tremens Hypoglycemia Hypoxia
Transient ischemic attack (TIA)
Sleep disorders
Migraine
Movement disordersSpecial considerations in children Breath-holding spells Apnea Night terrors Sleepwalking
Blood investigations◦Blood sugar◦Acidosis◦Electrolytes◦Serum creatine kinase activity◦Serum prolactin
Increased in Generalized and Complex partial seizures
Not increased in Absence and Myoclonic seizures
◦Rise in ACTH and cortisol Post ictal phase
Screen for toxins ◦Blood◦Urine
Lumbar puncture◦ Indicated
if there is suspicion of meningitis or encephalitis
All HIV infected persons even in the absence of signs and symptoms of infection
◦ In 15% patients after a seizure - WBCS – 10 – 50 /mm3 Slight increase in protein content
Diagnosis of epilepsy Classification of seizures / epilepsy Selection of AEDs Prognosis
PROLONGED RECORDINGS◦Ambulatory EEG recordings◦ Inpatient evaluation with continuous video
and EEG monitoring
INTRACRANIAL MONITORING
MAGNETO – ENCEPHALOGRAPHY
Indications – New onset seizures A fixed focal deficit Failure of seizure control with first
line AEDs Recurrence of seizures after a stable
control of seizures with continued AEDs
Change in seizure pattern Worsening of seizures
Computed Tomography Magnetic Resonance Imaging (FLAIR) Functional Magnetic Resonance
Imaging◦ Positron Emission Tomography◦ Single – Photon Emission Computed
Tomography
It means the state of the patient’s awareness of self and environment and his responsiveness to external stimulation and inner need.
ABCDE approach; Airway Breathing Circulation Disability Exposure
Assess level of consciousness: by GLASGOW COMA SCALESigns of meningeal irritation-• meningitis•SAHFundus•Raised ICP•SAH• Hypertensive encephalopathy
Pupil size and response to light Occular movements Posture and limb movement
Three components .score derived by adding the score for each component.Eye opening (4points) Verbal response (5 points)Best motor response(6 points)