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Dr Al Buick
Royal Devon and Exeter Hospital
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The Management of Acute Fits
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Outline•What do we mean by acute fits?• Different types of seizure• Causes of seizures•Management of acute seizures• Complications of seizures• Some quick cases
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Definitions – what does it all mean!
Acute Fits EpilepsyStatus
Epilepticus
Meducation The Medical Education Network www.meducation.net
Definitions – what does it all mean!
Acute Fits EpilepsyStatus
Epilepticus
What we might also call an acute seizure
Definitions – what does it all mean!
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A prolonged seizure or seizures repeated frequently enough to prevent recovery between episodes occurring over a period of 20-30 minutes.
Acute Fits EpilepsyStatus
Epilepticus
Definitions – what does it all mean!
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Recurrent episodes of intermittent brain dysfunction due to a sudden, disorderly, and excessive neuronal discharge. This can manifest as a seizure.
Acute Fits EpilepsyStatus
Epilepticus
Different types of seizure
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Seizures
Partial Generalised
Simple Complex
Absence Myoclonic Tonic-Clonic Tonic Atonic
Different types of seizure
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Seizures
Partial Generalised
Simple Complex
Absence Myoclonic Tonic-Clonic Tonic Atonic
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So what can cause a seizure?
Causes of seizures- Intracranial
Underlying brain pathology
• Underlying brain abnormality• Raised intracranial
pressure• Cerebral tumour• Cerebral oedema• Pregnant – Ecampsia
• Stroke• Thrombo-embolic• Haemorrhagic
• Brain infections
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GIANT CELL TUMOR, 14 MONTHS WITH SEIZURES
Extracranial- We could all suffer fits given the right situation
Pyrexia
Biochemical• Sodium, Glucose • Calcium, magnesium• Urate
Hypoxia – (e.g. Carbon monoxide poisoning)
Causes of seizures- Extracranial
Drugs• Prescribed• Recreational• Withdrawal
Management of seizuresYou are the F1 on call and it is 3am. You receive a bleep from one of the wards….
“Could you come and see this patient….. they are having fits and we don’t know what to do….. Please
come quickly…”
Management
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A
B
C
D
Airway
Breathing
Circulation
Disability
Is their airway patent?Give airway management if needed
Management
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A
B
C
D
Airway
Breathing
Circulation
Disability
• What is the respiratory rate?• What are their oxygen saturations• Give oxygen if needed
Management
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A
B
C
D
Airway
Breathing
Circulation
Disability
• Heart rate• Blood pressure• Peripheral perfusionCapillary refill time
Management
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A
B
C
D
Airway
Breathing
Circulation
Disability
• Other signs• ? Head injury• ? Bleeding• ? Sign of infection
Don’t Forget Glucose
Management of fits – Stepwise appraoch
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Initial A,B,C,D
Benzodiazepine
Phenytoin
Paralysis and
ventilation
Start treating underlying
cause
Management of fits – Stepwise appraoch
Meducation The Medical Education Network www.meducation.net
Initial A,B,C,D
Benzodiazepine
Phenytoin
Paralysis and
ventilation
Start treating underlying
cause
Benzodiazepine
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If fit does not resolve after a few minutes consider giving a benzodiazepine
Action Enhance effect of GABA which is the main inhibiting neurotransmitter Therefore reduce the excessive neuronal discharge
Benzodiazepine
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Side effects to be aware of Sedating and muscle-relaxing action Suppressed breathing Hypotension (worse with IV) Reduced conscious level Nausea Euphoria
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BenzodiazepineDrug Peak onset Half life
Midazolam About 1 hour Short (3 hours)
Lorazepam About 3 hours Medium (15 hours)
Diazepam About 2 hours Long (30+ hours)
Chlodiazepoxide About 3 hours Long (30+ hours)
Management of fits – Stepwise appraoch
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Initial A,B,C,D
Benzodiazepine
Phenytoin
Paralysis and
ventilation
Start treating underlying
cause
PhenytionWorks on sodium channels Blocks voltage-sensitive sodium channels in neurons Delay in neuronal electrical recovery from inactivation Inhibitory effect is dependent on the voltage and frequency of neural cell firing by selectively blocks neurons that are firing at high frequency
PhenytionPharmicokinetics Mainly hepatic break down Zero order kinetics
PhenytionSide effects
Beware of toxicity as zero order Arrhythmias (it is a class 1b antiarrhyhmic)
Bradycardia HypotensionBradykinesia, ataxia Sedation, confusion Teratogenicity
Management of fits – Stepwise appraoch
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Initial A,B,C,D
Benzodiazepine
Phenytoin
Paralysis and
ventilation
Start treating underlying
cause
Paralysis and ventilation
If seizure not managed by the initial methods
Amy need to consider paralysis and ventilation Should be done in ITU Expert help required
Complications of Seizures
SUDEP - Sudden Unexpected Death in Epilepsy
Brain injury
Physical Injury• Direct from fit – Tongue biting fitting• Driving?
A few clinical cases…
Case 1A 21 year old diabetic girl presents to the emergency department having been found out shopping on a Saturday morning. She was reported previously well by her friends and had even been out for some drinks the night before.
Her friends tell you she was acting strange and then collapsed. She not not very responsive and 10 minutes later she started fitting.What else do you want to know and what are you going
to do?
Case 2A 84 year old woman is brought in by ambulance having been found at home by her son on the floor. She was unresponsive and has been fitting on an off since she had been found.
Her son reports she is normally fit and well and only has bad arthritis, recently given “some sort of patch of the pain”
What else do you want to know and what are you going to do?
Case 3
A 20 year old motorcyclist was found having crashed in to a wall. He was brought in by air ambulance. He is barely conscious but responds to pain.
He is fitting every 5 minutes and has been for 45 minute since he was found.
What else do you want to know and what are you going to do?
QUESTIONS