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!