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Chapter 10
Introduction
Seizures are among the earliest known and still least understood afflictions. They herald dozens of anomalies, ranging from head injury to hypoxia and from epilepsy to hypoglycemia.
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Topics
Anatomy & Physiology
Updated Classification & Terminology
Pathophysiology
Differential Diagnosis
C ASE S TUDY
Situation
You and your partner are covering an evening football game at a local high school when you are summoned by a police officer for a fan who is having a seizure.
As you thread your way through a crowd of people, you encounter a 35-year-old man who is apparently having a seizure on the ground.
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C A S E S T U D Y F O L L O W-U P
Situation
History
Patient has been actively seizing x 10 minutes. Per wife, patient has just been weaned off of Dilantin for Sz. disorder; no seizures x 2 months.
Patient felt fine when he arrived at game; went for refreshments, began feeling funny, sat down & began seizing. Convulsions persisted until your arrival.
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Nature of Consciousness
Arousal (state of wakefulness)
Mediated by reticular activating system Can exist independently of awareness
Awareness
Provided by cerebral hemispheres Self Surroundings Response to surroundings
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Cranial Anatomy
The Brain & Its Membranes
Dura mater Pia mater Arachnoid membrane
Cranium
Cranium Brain
2 Cerebral hemispheres
DIENCEPHALON
Midbrain Pons
Cerebellum
BRAINSTEM Medulla
oblongata
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Tonic-clonic
- Sudden loss of consciousness & motor function - At least some disruption of respirations - Postictal phase involving fatigue, gradual recovery w / amnesia
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Complex
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Pathophysiology
Abnormal excessive discharges of cerebral neurons trigger:
250x normal ATP consumption 250% increase in cerebral blood flow 60% rise in O2 consumption 20% increase in lactic acid
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Differential Diagnosis
Seizures can be idiopathic or secondary to other disorders that fall into the following basic categories:
CNS injury / dysfunction Metabolic disturbance Infection
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Head Trauma
History!
- Mechanism of injury - Pattern of mentation
Medical Dysfunction
Structural lesion (seldom presents acutely) Stroke Be aware of time!
- Unilateral facial findings Current therapies are effective - Ocular signs in treating some stroke patients. - Hemiparesis - Generalized signs may occur late or (if insult is profound) early Free blood (highly irritating)
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Metabolic Disorders
Hypoperfusion Hypoxia Hypercapnea Hypo / hyperglycemia Electrolyte disturbances (highly irritating) Drug concentrations (therapeutic & non-therapeutic) Alcohol withdrawal Poisons/abnormal metabolyte levels
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Important to Note...
In addition to recreational substances, many therapeutic medicines have seizures as side-effects. Watch for:
Aminophylline (theophylline) Lidocaine Phenothiazines Physostigmine Tricyclic antidepressants Some antihypertensives
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Important to Note...
Sudden changes in the serum concentration of an anticonvulsant medication is a common cause of seizures. Examine the patients person & surroundings for:
Dilantin (phenytoin) Phenobarbital Zarontin (ethosuximide) Tegretol (carbamazepine) Depakene or Depakote (valproic acid) Mysoline (primidone) Clonopin (clonazepam) Tranxene (clorazepate) Felbatol (felbamate) Neurontin (gabapentin)
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Infectious Diseases
Meningitis: viral / bacterial infection of meninges
- Common in kids but also present in adults - 50-60% fatal if untreated
Once you have ensured your own safety, remove any obstacles that could injure the patient.
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
Bystanders history
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
Consider under-dosing or non-use of prescribed anticonvulsants. Consider seizures as sideeffects of some prescribed & street substances.
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
Seizures?
Diabetes?
Metabolic disorders?
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
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SAMPLE Questions
S igns & symptoms A llergies M edications P ast medical history L ast oral intake E vents prior to illness
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(continued)
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C A S E S T U D Y F O L L O W-U P
Situation
You and your partner are covering an evening football game at a local high school when you are summoned by a police officer for a fan who is having a seizure.
As you thread your way through a crowd of people, you encounter a 35-year-old man who is apparently having a tonic-clonic seizure on the ground.
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C A S E S T U D Y F O L L O W-U P
Situation
History
Patient has been actively seizing x 10 minutes. Per wife, patient has just been weaned off of Dilantin for Sz. disorder; no seizures x 2 months.
Patient felt fine when he arrived at game; went for refreshments, began feeling funny, sat down & began seizing. Convulsions persisted until your arrival.
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C A S E S T U D Y F O L L O W-U P
Assessment & Treatment
Impression: prolonged full-body tonic-clonic seizure. Rx: Move crowd back, protect patients head, insert nasal airway & administer on 100% O2 via non-rebreather mask. IV inserted in forearm, 5 mg diazepam admin. slow IVP & seizure subsides. Oropharynx suctioned briefly. Vitals: P=96, bounding; R=14, shallow; BP=132/60. ECG reveals NSR. Blood glucose=142 mg/dl. Patient responding to voice, but disoriented. No evidence of trauma.
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C A S E S T U D Y F O L L O W-U P
Assessment & Treatment Outcome
Patient agrees to transport, which is uneventful.
Patient regains normal mentation. States he has recently been weaned off of Dilantin, felt fine tonight, has no recollection of event.
Physician readjusts patients meds; he does well.
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