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Seizures and other such Spells

Seizures and other such Spells. 27th Annual Family Medicine Review Austin, Texas APRIL 2011 Jeffrey Clark, D.O. things that come and go. Spells. SZ Migraine TIA/Syncope. Hypoglycemia Intoxication Psychiatric (spells) Narcolepsy BPPV. The Significance of Syncope.

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Seizures and other such Spells

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  1. Seizures and other such Spells 27th Annual Family Medicine Review Austin, Texas APRIL 2011 Jeffrey Clark, D.O.

  2. things that come and go Spells • SZ • Migraine • TIA/Syncope Hypoglycemia Intoxication Psychiatric (spells) Narcolepsy BPPV

  3. The Significance of Syncope The only difference between syncope and sudden death is that in one you wake up.1 1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412.

  4. The Significance of Syncope • Some causes of syncope are potentially fatal • Cardiac causes of syncope have the highest mortality rates 1 Day SC, et al. Am J of Med 1982;73:15-23. 2 Kapoor W. Medicine 1990;69:160-175. 3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189. 4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.

  5. Structural Cardiac Abnormalities Cardiac Rhythm Abnormalities • Hx of MI / Ischemic injury • CHF / decreased EF • Valvular abnormalities • Outflow obstruction • Wall motion abn. • Bradycardia • Sick sinus • AV block • Tachycardia • VT • SVT • Long QT Syndrome

  6. 9 Day S, et al. Am J Med. 1982; 73: 15-23. 10 Stetson P, et al. PACE. 1999; 22 (part II): 782. 5 Kapoor, JAMA, 1992 6 Krahn, Circulation, 1995 7 Krahn, Cardiology Clinics, 1997. 8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8. 1 Kapoor, et al N Eng J Med, 1983. 2 Kapoor, Am J Med, 1991. 3 Linzer, et al. Ann Int. Med, 1997. 4 Kapoor, Medicine, 1990. * Structural Heart Disease †MRI not studied

  7. Subclavian Stenosis Subclavian Stenosis (b) Delayed Image (a) aortogram Arch aortogram initially shows apparent absence of left vertebral artery . However, delayed imaging on the same patient, the left vertebral artery (green) fills retrogradely to supply the left subclavian artery, (confirming left subclavian steal phenomenon secondary to a severe stenosis of the proximal left subclavian artery)

  8. Your Patient • 21 year old college student who “keeps blacking out without seizure activity”… • Evaluated in the ED this afternoon, phenytoin (Dilantin) level is “normal”... • What other tests do you want?… • What are these spells (? Seizures ?) • If so, what type of seizure is it (? And, does it matter ?) • How do you know they are not in status epilepticus? • What should your evaluation include? • How does the AED level help direct your plan? • What will you do if seizures continue in spite of management?

  9. Will it happen again? (risk of recurrence) If it does…

  10. Seizures: Focal vs. Generalized Onset Focal Onset (partial onset) Generalized Onset (primarily generalized) • Absence • Atonic • Myoclonic • Generalized tonic-clonic • Partial motor • Partial sensory • Complex partial • Generalized tonic clonic

  11. Epilepsy syndromes • Juvenile myoclonic epilepsy • Benign neonatal familial convulsions • Childhood & Juvenile absence • Febrile seizures • West syndrome • Lennox-Gastaut syndrome • Rolandic epilepsy

  12. Complex Partial Absence • Warning (aura) Often no • Duration 30-120 sec 10-20 sec • Occur (#) 1-3/day 10-20/day • Automatisms Often Occas. • Amnestic (for spell) Partially Totally • Post-ictal (tired) YES no • Focal abn (ex or scan) Often no • Family hx no YES

  13. Neurontin (1993) • Felbatol (1993) • Lamictal (1994) • Topamax (1996) • Gabitril (1997) • Keppra (1999) • Trileptal (2000) • Zonegran (2000) • Lyrica (2004) • Vimpat (2008) • Sabril (2009) • Phenobarbital (1912) • Dilantin (1938) • Ethosuximide (1955) • Tegretol (1974) • Valproate (1978) Vagus Nerve Stimulator (1997)

  14. 47 % 36 % First Drug Tried Not Controlled 4 % 13 % Second Drug Success of AEDs in Previously Untreated Epilepsy Pts. (470) NEJM 2000;342:314-319. Kwan P, Brodie MJ.

  15. Dilantin dose increased from 400 to 500 per day

  16. What you should now know: • SPELLS of… Vision, consciousness, weakness, etc… • Avoid terms such as “Blacking Out”, “Passing Out”, “Fell Out” • Syncope definition, evaluation, prognosis • Epilepsy, Tx & eval of epilepsy, Control of epilepsy • “Normal” AED Level • Therapeutic AED level • Toxic Level • “Post-ictal” • “Petit Mal” (Absence) sz • Convulsive syncope • Tussive Syncope & Micturation Syncope • “Hypoglycemia” spells • “Drop Attacks” due to “V-B Insufficiency” or “Subclavian Steal” • Carotid dz (? Causing syncope/spells with LOC) • Bank Robberies and other complex activity during seizures or somnambulism

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