Chapter 19: Seizures and Syncope Study Guide

Introduction to Seizures and Syncope

  • Seizure definition: A sudden and temporary alteration in brain function caused by random, continuing electrical discharges in the brain. This results in sudden onset changes in mental activity and behavior.

  • Epilepsy: A common chronic cause of recurrent seizures.

  • Seizures are not always idiopathic; they frequently result from underlying medical conditions or traumatic injuries.

Pathophysiology of Seizures

  • Primary (Unprovoked) Seizures:

    • These occur from genetic or unknown (idiopathic) causes.

    • Generalized seizures: Involve both cerebral hemispheres of the brain and the reticular activating system, resulting in a loss of consciousness.

    • Partial seizures: Involve only one cerebral hemisphere. These are categorized into:

    • Simple partial seizures.

    • Complex partial seizures.

  • Secondary (Provoked) Seizures:

    • Result from an underlying insult or condition (e.g., trauma, hypoglycemia).

    • These seizures are typically generalized.

Common Causes of Secondary (Provoked) Seizures

  • High fever (febrile seizures).

  • Noncompliance with seizure control (anti-epileptic) medications.

  • Known seizure disorder (epilepsy).

  • Infection (e.g., meningitis, encephalitis).

  • Poisoning or toxic ingestion.

  • Hypoglycemia (low blood sugar\text{low blood sugar}).

  • Hyperglycemia (high blood sugar\text{high blood sugar}).

  • Traumatic brain injury (TBI).

  • Shock.

  • Hypoxia (low oxygen levels\text{low oxygen levels}).

  • Stroke (Cerebrovascular Accident).

  • Drug or alcohol withdrawal.

  • Cardiac dysrhythmias.

  • Hypertension (high blood pressure\text{high blood pressure}).

  • Pregnancy complications, specifically Eclampsia.

  • Blood electrolyte imbalances (e.g., sodium Na+\text{Na}^{+}, calcium Ca2+\text{Ca}^{2+}).

  • Hyperthermia.

  • Idiopathic (unknown) triggers.

Status Epilepticus

  • Definition: A life-threatening emergency characterized by generalized motor seizures that last more than 30 minutes30\,\text{minutes}, or seizures that occur consecutively without the patient regaining responsiveness between episodes.

  • Presenting as a critical medical priority requiring immediate intervention.

Generalized Tonic-Clonic Seizures (Grand Mal)

  • Involvement: Cerebral hemispheres and the reticular activating system.

  • Consciousness: The patient is neither awake nor aware.

  • Stages of a Generalized Tonic-Clonic Seizure:

    • Aura: A sensory perception (sound, smell, or feeling) that serves as a warning of an impending seizure.

    • Loss of Consciousness: Occurs immediately following or during the aura.

    • Tonic Phase: Characterized by extreme muscle rigidity.

    • Hypertonic Phase: Extreme muscle tension.

    • Clonic Phase: Convulsions involving rhythmic muscle contraction and relaxation.

    • Postictal State: The recovery phase where the patient is altered, sleepy, or confused as the brain recovers.

  • Emergency Medical Care: If the seizure has ceased, provide reassurance, conduct a thorough assessment, and follow protocols for transport. Status epilepticus requires immediate advanced life support (ALS) or transport.

Other Types of Generalized Seizures

  • Absence Seizure: Brief loss of consciousness without loss of muscle tone (blank stare).

  • Myoclonic Seizure: Brief, sudden contractions of a muscle or group of muscles.

  • Tonic Seizure: Sudden onset of muscle stiffness / rigidity.

  • Atonic Seizure: "Drop attack" characterized by a sudden loss of muscle tone.

  • Febrile Seizure: Seizures associated with high fever, most common in pediatric patients.

Partial (Focal Onset) Seizures

  • Simple Partial Seizure (Focal Onset Aware Seizure):

    • The patient remains awake and aware.

    • Involves abnormal movements or sensations in one area of the body.

    • Types: Motor, sensory, autonomic, or psychic presentations.

    • Note: These may spread and become generalized seizures.

  • Complex Partial Seizure (Focal Onset Impaired Awareness Seizure):

    • Duration: Usually lasts 30 seconds30\,\text{seconds} to 2 minutes2\,\text{minutes}.

    • Consciousness: The patient remains awake but is not aware (impaired awareness).

    • Presentation: Starts with a blank stare, followed by random movements (automatisms like lip smacking or picking at clothes). The patient may repeat words/phrases and will not respond to commands.

  • Secondarily Generalized Seizure: A partial seizure that spreads to involve the entire brain, transitioning into a generalized tonic-clonic state.

Psychogenic Non-Epileptiform Seizures (PNES)

  • Also referred to as psychogenic seizures.

  • There is no change in brain electrical physiology during the event.

  • Often lasts longer than a true generalized tonic-clonic seizure.

  • Distinctive marks: Forward-thrusting pelvic movements and the head being turned from side to side.

Assessment-Based Approach to Seizure Activity

  • Scene Size-up:

    • Look for evidence of trauma (falls), poisoning (pill bottles), or medical IDs.

    • Move objects and furniture away from an actively seizing patient to prevent injury.

    • Warning: Seizure activity may precede a cardiac arrest.

  • Primary Assessment:

    • Airway: Check for secretions, blood, or vomit; utilize suctioning as necessary.

    • Breathing: Assess adequacy; consider positive pressure ventilation (PPV) or oxygenation.

    • Circulation: Assess pulse and skin condition.

    • Transport Priority: Determine if the patient is high priority based on critical findings.

  • High-Priority Transport Circumstances:

    • Patient remains unresponsive after the seizure.

    • Airway, breathing, or circulation is compromised.

    • Status epilepticus is suspected.

    • History of pregnancy, diabetes, or trailing injury.

    • Seizure occurred in water (e.g., pool, lake).

    • Evidence of head trauma causing the seizure.

    • No prior history of epilepsy or seizure disorders.

    • Seizure resulted from drug or alcohol withdrawal.

  • Secondary Assessment:

    • Head assessment: Sign of trauma or tongue biting.

    • Extremities: Check for weakness or paralysis on one side (Todd\'s Paralysis) or trauma.

    • Vital Signs: Assess pulse, BP, and respirations.

    • Blood Glucose: Always assess blood glucose levels (BGL\text{BGL}) to rule out hypoglycemia.

    • History: Identify medications and duration of seizure activity.

Signs and Symptoms of Seizure Activity

  • Aura.

  • Loss of consciousness.

  • Convulsions (generalized).

  • Biting of the tongue.

  • Excessive oral secretions (saliva).

  • Urinary or bowel incontinence.

  • Hyperventilation and tachycardia.

  • Postictal confusion or lethargy.

Emergency Medical Care and Management

  • Physical Protection: Do not restrain the patient; move objects to prevent strikes.

  • Airway Management:

    • Position the postictal patient in the lateral recumbent (recovery) position.

    • Use a nasopharyngeal airway (NPA\text{NPA}) if the patient is unable to maintain their own airway (avoid oropharyngeal airways in seizing patients).

    • Suction the airway to clear blood, vomit, or secretions.

  • Oxygenation:

    • Administer oxygen to maintain saturation levels.

    • Use PPV if breathing is inadequate.

  • Reassessment:

    • Monitor for additional seizure activity.

    • Be aware of prehospital medications used by ALS to stop seizures (e.g., Diazepam, Lorazepam).

Syncope (Fainting)

  • Definition: A sudden, temporary loss of consciousness resulting from a temporary interruption of cerebral perfusion.

  • Characteristic: Consciousness is usually regained immediately upon becoming supine.

  • Causes: Increased parasympathetic influence, vasovagal response, or orthostatic hypotension (sudden standing).

  • Convulsive Syncope: Twitching movements or a very brief generalized convulsion may occur, often confusing bystanders into thinking it was a seizure.

  • Differentiation from Seizure:

    • Syncope usually begins in a standing/upright position; seizures can occur in any position.

    • Syncope often involves light-headedness or dizziness; seizures may involve an aura.

    • Syncope has a sudden return to consciousness; seizures involve a gradual return (postictal).

    • Skin in syncope: Cool, moist, and pale.

    • Skin in seizure: Warm and sweaty.

Pediatric Seizure Considerations

  • Possible causes include: Epilepsy, head injury, meningitis, hypoxia, drug overdose, metabolic/electrolyte abnormalities, brain tumors, and hypoglycemia.

  • Febrile Seizures: Caused by a rapid spike in body temperature; generally benign but require evaluation.

  • Assessment focus: Use AVPU scale, take a thorough history, and differentiate from syncope.

Medications Commonly Used in the Treatment of Epilepsy

  • Bivaracetam (Briviact)

  • Carbamazepine (Atretol, Carbagen SR, Epitol, Mazepine, Tegretol, Tegrital, Teril, Timonil)

  • Carbamazepine XR (Carbatrol, Tegretol XR)

  • Clobazam (Frisium, Onfil)

  • Clonazepam (Epitril, Klonopin, Rivotril)

  • Diazepam (Diastat, Valium)

  • Divalproex Sodium (Depacon, Depakote, Epival)

  • Elicarbazepine Acetate (Aptiom)

  • Ethosuximide (Zarontin)

  • Ezogabine (Potiga)

  • Felbamate (Felbatol)

  • Gabapentin (Neurotin)

  • Lacosamide (Vimpat)

  • Lamotrigine (Lamictal)

  • Levetiracetam (Keppra)

  • Lorazepam (Ativan)

  • Oxcarbazepine (Oxtellar, Tripetal)

  • Perampanel (Fycompa)

  • Phenobarbital

  • Phenytoin (Dilantin, Epanutin, Phenytek)

  • Pregabalin (Lyrica)

  • Primidone (Mysoline)

  • Rufinamide (Benzel, Inovelon)

  • Tiagabine Hydrochloride (Gabitril)

  • Topiramate (Topamax)

  • Valproic Acid (Convulex, Depakene, Depakine, Orfiril, Valporal, Valprosid)

  • Vigabatrin (Sabril)

  • Zonisamide (Zonegran)

Case Study: Seizure Response

  • Incident: EMTs Ana Salinas and Loren Dyer respond to a residential call for a man in his early 30s30\text{s} (Dan).

  • Initial Assessment: Dan is unresponsive with increased respirations, copious oral secretions, and urinary incontinence. He fell from a chair while playing cards.

  • Interventions: Dan is turned to his left side (lateral recumbent), and his airway is suctioned. Oxygen saturation is observed at 99%99\%.

  • Physical Findings: Tongue was bitten; no evidence of head, trunk, or extremity trauma.

  • Seizure Duration: The seizure lasted approximately 2 minutes2\,\text{minutes}.

  • History: History of seizures; prescribed Carbamazepine. Prescription check suggests missed doses over the last 2 weeks2\,\text{weeks}.

  • Disposition: Dan regained responsiveness to verbal stimuli but remained sleepy and altered. Due to medication non-compliance and altered status, he was transported to the Emergency Department (ED\text{ED}).