Please enable JavaScript.
Coggle requires JavaScript to display documents.
A 48-year-old man is brought to A&E after he was found unresponsive on…
A 48-year-old man is brought to A&E after he was found unresponsive on the floor. According to his wife, he had been completely well and his usual self, 15 minutes prior to being found. The ambulance staff noted he had 2 short episodes that were suggestive of generalized tonic-clonic seizures
first seizure
generalized (grand-mal)
(1) tonic stiffening, often with biting of tongue, apnoea, ↑ sympathetic tone with ↑ BP & ↑ HR, then (2) clonic limb jerking, then (3) postictal drowsiness ± incontinence.
-
infective
meningitis (including TB), encephalitis, cerebral abscess, and parasitic dx (cerebral malaria, cysticercosis).
Examine for fever, signs of meningism (stiff neck, photophobia, Kernig’s, Brudzinski’s)
↑ ICP (papilloedema, CN VI palsy, pupillary dilation, Cushing’s reflex)
-
metabolic
do bloods for ↓ glucose, ↑ Na, ↓ Na, ↓ K, ↓ Ca, ↓ Mg, uremia, hyperammonemia. stat hypocount.
drugs
tricyclics, cocaine, tramadol, alcohol or benzodiazepine withdrawal.
-
stroke
-
-
Emergent CT (or MRI, if obtainable acutely) may be indicated if there is concern for a bleed.
acute trauma
the precipitating insult (e.g. skull fracture, intracranial haemorrhage, penetrating injury) is usually obvious.
structural
scarring
post- stroke, trauma, brain surgery, or perinatal insult (e.g. cerebral palsy). The strokes may hv been subclinical, in which case a careful neuro exam may identify motor or cortical signs.
-
degnerative
hippocampal sclerosis
(temporal lobe seizures), Alzheimer’s dx
-
recurrent seizure
A diagnosis of epilepsy may be made. The workup identified in the approach to first seizure, including EEG, should be performed if not already done. Initiation of antiepileptic drugs will be the next task; in this the seizure classification is of management significance (treatment is not discussed in these notes).
breakthrough seizure
-
Drug compliance: check serum AED levels (not possible for all drugs). pursue compliance issues including tolerance of side effects.
Precipitating factors: sleep deprivation, alcohol, stress, etc (patient dependant)
Consider reversible causes: known epilepsy does not exclude a new stroke, meningitis, or electrolyte imbalance. At least do a neuro exam, FBC, electrolytes, glucose.
-
diagnoses of exclusion
Simple febrile seizure: a single GTC episode lasting <15min, in a febrile child 6m-6y old with no neurological abnormality or developmental delay.
-