SFGH 1.27 seizure pearls from neuro report

  • Great mnemonic for thinking about differentials for all neuro problems:
    • V – vascular
    • I – infection
    • T – toxin
    • A – Autoimmune
    • M – meds/mass
    • I – idiopathic (or psychogenic, for seizures)
    • N – neoplasm
    • C – congenital
  • If you witness a seizure, pay attention to type (focal vs general) and time the seizure. If you notice a gaze deviation at the very beginning it can be helpful in identifying the more affected hemisphere.
  • Check electrolytes and utox and look for signs of infection as the cause of the seizure or as cause for lowered seizure threshold in someone with a seizure disorder
  • Treat with benzos only if the seizure has not stopped after 2 mins
    • Give IV Ativan 2-4mg if they have an IV. If not, you can give IM midazolam, and there are buccal and nasal spray Ativan formulations, as well.
    • Status epilepticus is defined as more than 5 minutes of continuous seizure or 2+ seizures between which there is incomplete recovery of consciousness
    • Next steps for status epilepticus include fosphenytoin load, then keppra, Depakote, propofol or phenobarb, though it is not yet known which of these medications is most effective (SFGH has a trial going on now to find out!)
    • For status patients, hydrate after the seizure breaks and get imaging starting with non-con-head CT with MRI at some point if CT is unrevealing (imaging may not be necessary if you know the likely etiology, such as med non-compliance, etc)
  • For first time seizures, get an EEG and MRI, ideally within 1 week after the seizure. If both are normal, there is a <20% chance of repeat seizure and observation is recommended. If either EEG or MRI is abnormal, treat with anti-epileptics and address any abnormalities identified, as risk of repeat seizure is high (highest within the first two years).
  • Some AEDs are associated with hypersensitivity reactions.
    • For Asian populations, check an HLA*B1502 before starting lamotrigine, which is associated with SJS/TEN
    • Check HLA-B*1502 for Asian patients and HLA-A*3101 for patients of any ethnicity before starting carbamazepine for SJS/TEN

Evernote link: https://www.evernote.com/shard/s300/sh/6129cb8b-a1e1-41f8-b673-a7627596517c/0b7ff2363528055253cc9d69e2ddaec1

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