What Every Hospitalist Should Know About Seizures and Epilepsy Questions and Answers

Transcription

1 Seizure Classification What Every Hospitalist Should Know About Seizures and Epilepsy Q1. Why is it important to classify seizures? A1. Appropriate classification is the first step to effective seizure treatment. It is also important that everyone on the care team has the same understanding of how seizures can be classified to ensure efficient and effective communication. Q2. What is the difference between generalized and partial seizures? A2. Generalized seizures originate in both sides of the brain. Partial seizures (also called focal seizures ) originate in one side of the brain. In some cases, partial seizures can secondarily generalize meaning they spread to both sides of the brain. 1 Q3. What criteria are used to classify seizures and what are the classifications? A3. Seizures can be classified based on clinical presentation and parts of the brain affected. Both partial and generalized seizures can be further classified. Partial seizures: Simple partial seizures do not cause loss of consciousness; patients may experience confusion, jerking movements, usually on one side of the body, tingling or odd mental and emotional events. Complex partial seizures may cause a brief loss of consciousness; patients may appear to others as motionless with a vacant stare. Unilateral dystonic posturing and automatisms may also occur in patients experiencing a complex partial seizure of temporal lobe onset. 2 This is the most common seizure type in adults. These seizures may result in loss of judgment and involuntary or uncontrolled behavior. 3 Generalized seizures involve both sides of the brain and almost always affect consciousness. Tonic-clonic seizures occur in two phases. During the tonic phase, the muscles suddenly contract, which may cause the patient to fall and lie stiffly. In the clonic phase, the muscles alternate between relaxation and rigidity. 4 The seizure usually lasts 1-2 minutes, after which the patient may not remember having the seizure and may appear confused or fatigued. 5 Tongue laceration and urinary incontinence are also common. 6 Absence seizures are brief losses of consciousness that can go undetected and can occur up to 100 times a day. 7 Eye fluttering is also typical. 8 Myoclonic seizures appear as brief jerky contractions of specific muscle groups. They usually occur at the same time on both sides of the body, but may occur unilaterally in cases of juvenile myoclonic epilepsy. 9,10 Epilepsy campaign was created in partnership with and sponsored by UCB, Inc. Dedicated to providing the highest quality care for hospitalized patients, and committed to enhancing the practice of hospital medicine by promoting education, research and advocacy, SHM developed the content of this program to enhance hospitalists understanding of epilepsy and its treatment. UCB is a biopharmaceutical company dedicated to improving the lives of patients with serious diseases through research, development, and manufacturing medicines. This SHM campaign and its materials are in full compliance with the Council of Medical Specialty Societies (CMSS) Code for Interaction

2 Atonic (akinetic) seizures cause a sudden and general loss of muscle tone which may result in a fall, also known as a drop attack. Atonic seizures may also involve only one part of the body such as head or neck, resulting in a head drop. 11 Q4. Why it is important for hospitalists to know the different types of seizures? A4. Hospitalists need to know how to classify seizures because it is a key step in making a diagnosis and, if necessary, developing an epilepsy treatment plan with the goal of longterm seizure freedom with minimal medication side effects. Additionally, the patient s primary care physician or neurologist needs to have specific details to help ensure that appropriate treatment is provided after discharge. Q5. What s the difference between provoked and unprovoked seizures? A5. Provoked seizures can be linked to a direct stimulus that lowers the seizures threshold, such as head injury, stroke, alcohol withdrawal and metabolic or electrolyte disturbances. 12,13 Unprovoked seizures cannot be linked to an immediate underlying cause or stimulus; and they may indicate that the patient has epilepsy. 14 Seizure Evaluation and Diagnosis (e.g., epilepsy) Q6. Why is it important for hospitalists to conduct a thorough and detailed evaluation, including reviewing history for patients experiencing seizures? A6. Patient history that includes information about prior seizures and medications, along with physical examination, is the basis for differential diagnosis and determining the most appropriate treatment steps. Seizures may be a one-time provoked event or an indication of a chronic condition like epilepsy. 15 Q7. Are there protocol practices hospitalists should keep in mind during patients evaluations? A7. As with any patient, it is important to complete a thorough and ordered evaluation. 16 Check for history of seizures and any existing seizure-related diagnosis (e.g., epilepsy). Check current symptoms that may provoke seizures (e.g., fever and confusion may indicate encephalitis; recent trauma may indicate subdural hematoma). Look for clues that might help determine an underlying etiology (e.g., information on medic-alert bracelets or uncommon evidence of trauma). Review current medications and check for concomitant diagnoses that would indicate the need for imaging and laboratory evaluation for electrolyte disturbance. After evaluation, determine the need to involve a neurologist for further consultation.

3 Treatment Considerations Q8. When should one treat status epilepticus? A8. It is imperative to treat patients with status epilepticus (SE) quickly. In clinical practice, any seizure lasting more than five minutes should be treated as SE, given its low likelihood of spontaneous cessation. SE poses a mortality risk of nearly 20 percent. 17 Q9. How is status epilepticus treated? A9. One of the key treatment tenets is to abort the seizure as quickly as possible. First-line treatment is benzodiazapines. Second-line treatments include fosphenytoin, potentially followed by IV AEDs if control is not attained. Subsequent possible treatments include general anesthetics and continuous infusions of benzodiazapines. 18 Q10. What are the treatment considerations for epilepsy? A10. Once a diagnosis of epilepsy is made, the medication treatment options may differ from those used for acute seizure management. The goal of antiepileptic drug therapy is to eliminate seizures completely with minimal side effects. 19 There are many different epilepsy syndromes; the type of syndrome affects what therapy is prescribed. Medication Selection in Epilepsy Q11. What are the key considerations in choosing a medication for epilepsy treatment? A11. The key to appropriate antiepileptic drug (AED) choice is to know the type of epilepsy/seizure being treated. In addition, treatment decisions should be based on careful consideration of side effect profiles of AEDs, which vary considerably, and potential interactions between AEDs (especially those metabolized through the P450 cytochrome system) and other commonly prescribed medications. The goal of epilepsy management is for the patient to be seizure free with minimal medication side effects. Q12. Are there additional considerations specific to epilepsy treatment in a hospital setting? A12. Medication choices in the hospital are frequently made on the basis of expediency and route of administration. There are relatively few medications available in intravenous form, which is often the sole route available in hospitalized patients. In recent years, there has been an increase in the number of available AEDs. Q13. How effective are AEDs in managing epilepsy? A13. Approximately two-thirds of patients with recent onset epilepsy respond to AED monotherapy. While treatment with one drug remains the goal of AED therapy and provides adequate control for many patients, one-third of patients with epilepsy receive suboptimal seizure control on monotherapy. In these situations, a physician may prescribe different treatments until one is found to provide adequate seizure control for the patient. 20

4 Patients with Epilepsy Presenting for Surgery Q14. What are the areas of concern for surgical patients with epilepsy? A14. Pre-operatively, most patients with epilepsy can continue their normal medication and intra-operatively, general anesthesia typically acts as a potent AED. The post-operative period is when hospitalists may have to address specific concerns for patients with epilepsy. Q15. What are the post-surgical concerns for patients with epilepsy? A15. Management of post-surgical patients whose epilepsy is well controlled and who take medications with IV equivalents is straightforward. Patients with difficult to control epilepsy on multiple medications may benefit from the involvement of their primary neurologist, who has likely taken an extended period of time to arrive at the specific individual s medication regimen. These patients may benefit from close monitoring and attention to seizure precautions such as padded bedrails. For those on medications that do not have an IV equivalent and are unable to receive medications orally or enterally, a few considerations must be taken into account. An IV alternative will be appropriate if there is an extended period of time without oral treatment; or the patient has had poor seizure control; or the patient has had generalized convulsions, a recurrence of which would result in post operative morbidity. Discharge Considerations Q16. Why is discharge an important part of care for patients with seizures and epilepsy? A16. Patients with seizures are at increased risk of injury or death 21 and should be counseled about potentially risky activities, like swimming, taking baths, bicycling and of course, driving. Hospitalists should be aware of the laws concerning driving and seizures in their state. Additionally, if patients are leaving the hospital with a new diagnosis, they are likely to have many questions in the time following discharge. A thorough discharge plan will help them navigate these questions. Assurance of appropriate outpatient follow-up is critical for patients with epilepsy or new onset seizures. Q17. What are some things the hospitalists should discuss with patients at discharge? A17. Prior to discharge, hospitalists should carefully go over several points with their patients and caregivers: Discuss safety concerns. Activities such as swimming, driving and taking baths can be dangerous for patients with seizures or epilepsy. Review signs and symptoms of seizures and epilepsy. Some symptoms of seizures are subtle and it is important for patients and caregivers to be on the lookout for them. All patients should be counseled about the goal of treatment (seizure freedom with minimal side effects), and encouraged to get the appropriate care to achieve this goal.

5 Encourage appropriate outpatient follow-up care. Provide referrals to neurologists to help monitor the patients medication levels and asses if long-term treatment is necessary. In addition to the referral to an outpatient neurologist, provide other resources like the Epilepsy Foundation website, Consider factors that affect patient compliance (i.e., cost, lack of understanding about complex regimens, intentional medication skipping, etc.) and counsel patients appropriately. References 1 Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition P. Kotagal, MD, et al. Dystonic posturing in complex partial seizures of temporal lobe onset A new lateralizing sign. Neurology. February 1, 1989 vol. 39 no Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Centers for Disease Control and Prevention. Epilepsy. Accessed June 8, Cohen, R., Suter, C. Hysterical seizures: Suggestion as a provocative EEG test Annals of Neurology. Volume 11, Issue 4, pages , April Epilepsy Foundation. Seizures and Syndromes. Accessed June 8, Guerrini, R., Genton P. Epilepsia. Epileptic Syndromes and Visually Induced Seizures. Volume 45, Issue Supplement s1, pages 14 18, January Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Alfradique, I., Vasconcelos, M. Juvenile myoclonic epilepsy Arquivos de Neuro-Psiquiatria. Vol.65 no.4b São Paulo. December Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition National Institute of Health. Seizures and Epilepsy: Hope Through Research. Accessed June 8, Castilla-Guerra, L. Electrolytes Disturbances and Seizures. Epilepsia May:47(12): Centers for Disease Control and Prevention. Epilepsy. Accessed June 8, Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Manno EM. New management strategies in the treatment of status epilepticus. Mayo Clin Proc Apr;78(4): Review. 18 Manno EM. New management strategies in the treatment of status epilepticus. Mayo Clin Proc Apr;78(4): Review. 19 Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition Brodie, M, Schacter, S., Kwan, P. Fast Facts: Epilepsy. Third Edition