Approach to Seizure & Epilepsy

Seizure or syncope… who knows?  Now you do.

  • For seizure, expect a post ictal state (and ask for how long) and an elevated CK level if they were seizing for several minutes.
  • Warning! Convulsions, loss of consciousness, urinary incontinence can ALL occur in both syncope and seizure.

Causes of provoked seizures

  • Acute trauma
  • Medications: bupropion (Wellbutrin), tramadol, cocaine
  • Fever
  • EtOH/Benzo withdrawal
  • Extreme electrolyte disturbance: eg Na+ of 104 (less likely if it’s just 120 unless previous underlying seizure disorder)

ANY patient with syncope or seizure is legally not allowed to drive for 6 months (or more if they experience another event).  Here are the Penndot/ DMV forms you can fill out to revoke their license.  It’s not cruel.. you’re saving their and other people’s lives.

Acute CVA

Dr Paul Katz gave us a great intro to stroke!  Here is the link to the powerpoint. And here are the highlights:

  • CVA is the 5th leading cause of death.
  • Cerebral perfusion is key!
    • CORE trial found that the region of absent cerebral blood flow and CMRO2 (cerebral metabolic rate of oxygen) corresponded with the core of cerebral infarct.
    • SURROUND trial studied the ischemic penumbra, the region around the core in which cerebral blood flow is depressed out of proportion to CMRO2.
    • This region is salvageable with adequate perfusion pressure
  • Techniques for Increasing Perfusion Pressure
    • Hemodilution
    • Induced hypertension — treat hypotension!
    • Endarterectomy
    • Thrombolysis: tPA vs endovascular
Thrombolysis:
  • Despite an increased incidence of symptomatic ICH, patients treated with tPA within 3 hours of symptom onset showed improved clinical outcome at 3 months
    • later studies showed benefit for MCA occlusion up to 6 hours and vertibrobasilar occlusion up to 48 hours after symptom onset.
  • NIH tPA Trial: Patients given tPA were 30% more likely to have minimal or no disability at 3 months; this benefit was not associated with any increase in mortality.
  • Three 2015 studies (MR CLEAN, ESCAPE and SWIFT-PRIME all showed benefit of endovascular treatment of ischemic stroke.
Symptoms:
  • Isolated diplopia, vertigo, ataxia without weakness or dysphagia is highly unlikely to be stroke. However, in combination, they may be.
  • Do a FAST exam.
  • Use the NIH Stroke Scale (NIHSS)

Lecture video coming soon!

 

Basics of EKG, Part 1

Dr Greenberg started off our EKG series with an overview of how to read EKG’s.

Click here for the lecture powerpoint. Audio/video coming soon!

The most important point? If he, an electrophysiologist who has read thousands of EKG’s, still uses the following method to read every EKG.

  1. Rate
    • Count big boxes between each RR interval. For each big box in R-R interval, count down: 300bpm-> 150bpm->100bpm->75bpm->60bpm->50bpm…, or
    • Count QRS complexes in a 10s rhythm strip, multiply by 6
  2. Rhythm
    • p wave precedes each QRS?
    • QRS after every p wave?
    • Are the p waves and QRS complexes regular?
    • Is the PR interval constant?
  3. Axis (ventricular)
    1.  Simple limb lead method (not 100% but gets almost all)
      1. Normal: up in I and AVF.  OR: up in I, down in AVF, up in II
      2. L Axis: up in I, down in AVF, down in II
      3. R Axis: down in I
    2. R wave progression: RS complex should be isoelectric by V3-V4
  4. Intervals
    1. PR = atrial depolarization: normal 120-200msec
    2. QRS: normal 80-100msec (100-120msec: slightly wide; >120msec: wide)
    3. QTc: Normal <440msec (males) or <460msec (females)
      1. Rough estimate–normal less than 1/2 the RR interval
      2. Bazett calculation (QT / (sq root of RR interval in seconds)
  5. Morphologies
    1. P wave
    2. QRS Complex
    3. ST – T wave (ST depression, ST elevation, T wave changes)
    4. U wave

Other notables:

  • 1 small box = 0.04s (40msec)
  • 1 big box = 5 small boxes = 0.2s (200msec)

 

Common Infections – Dr Moyer

Darilyn Moyer started off our Intern Summer Conference Series with her essential Common Infections lecture.  Here are the highlights:

Below are The Daily Three, the top three points of each lecture:

  1. Pharyngitis DDx:
    • Group A Strep (5-10% in adults–not close to 100%!)
    • Other Bacteria (mycoplasma, C. pneumoniae, GC, anaerobes)
    • Resp viruses (adenovirus, influenza, parainfluenza, rhinovirus, RSV)
    • Other viruses (Coxsackie, Echo, HSV, **EBV**, **HIV**)
  2. Centor Criteria: (determines probability of GAS pharyngitis; if 4 criteria met: then can treat; 3 criteria: throat swab or treat; 2 criteria: no treatment though can test if personal preference; 0-1 criteria: unlikely GAS)
    1. Fever (by history)
    2. Tonsillar exudates
    3. Tender anterior cervical adenopathy
    4. Absence of cough
  3. UTI:
    • Uncomplicated cystitis: dysuria, urinary frequency/urgency; no fever or flank pain; (non-pregnant females only)
    • Complicated: same diagnostic s/s as uncomplicated; (all others: males, any medical illness such as DM, pregnant)
    • Acute Pyelonephritis: cystitis criteria with flank pain and/or fever
    • Females with h/o UTI have relatively high specificity for self-diagnosing UTI–> so you can treat over the phone if uncomplicated!

Check out the lecture powerpoint here! (password: same as the amion password)