ࡱ> kj'( ./ 00DArial0$J{ȷȷԳ0 0"DTahoma0$J{ȷȷԳ0 0" DWingdings$J{ȷȷԳ0 00DTimes New RomanȷȷԳ0 0  @n?" dd@  @@`` p8e()      **//      0AA@812 g42d2d 0 ppp@ <4BdBdhZ{ȷ80___PPT10 pp? %O =)Emergency Department management of the  first seizure in adultsAA(@ Dr Damien Mawer SHO in A&E LGI$  *Discussion Overview vWhy are  first fitters important? Was it a seizure? What causes them? How should they be investigated? Where do they go from A&E (is there a role for CDU)? What advice should we provide? + Evidence Base  Mainly retrospective studies Mainly in the American literature US guidelines are available (American College of Emergency Physicians. Ann Emerg Med 1997;29:706-24)(   ,DWhy are  first fitters important?" Common: 1 in 11 lifetime prevalence by 80, nearly 1% of A&E presentations Frequently  secondary : Underlying aetiology may be reversible Frequently recurrent: 27-71% after 3 years Life-style consequences: Vocational, recreational, social and financial -Was it a seizure? cDiagnosis based solely on history in A&E Witness account very important Diagnosis often varies between clinicians Using predefined criteria improves agreement rates Key features: aura, abrupt onset (may be focal), duration generally 90-120 seconds, usually altered consciousness, purposeless involuntary activity, followed by postictal state with amnesiadd(G    0Differential Diagnosis fSyncope Pseudoseizures Metabolic disorders Cerebrovascular disease Cardiac arrhythmias Hypotension (cg>    ,  `Migraine Hyperventilation/Panic disorder Fluctuating delerium Sleep disorders Paroxysmal vertigo(5  # 4BAetiology of  secondary seizures! Tumours (10-15% over 60) Vascular event: SAH, SDH, epidural haemorrhage, stroke (33-50% over 60), vasculitis Infection: meningitis, encephalitis, abscess Z(c   /  wMetabolic: hypoglycaemia, hyponatraemia, hypomagnesaemia, hypocalcaemia Toxic: alcohol, other agents Eclampsia TraumaxZx>   ?    5Investigations 1: Examination FULL PHYSICAL EXAMINATION Temperature Mental  status (not just GCS) FULL NEUROLOGICAL ASSESSMENT BM Evidence of trauma (fractures occur in 0.6% cases - missed on initial assessment in 60-80%)Z 6Investigations 2: Laboratory MANDATORY: glucose, U+E, calcium, ?pregnancy test ADDITIONAL (MENTAL STATUS NOT RETURNING TO NORMAL): FBC, magnesium, LFT, alcohol/toxicology, ABG/carboxyhaemoglobin, urinalysis, ECG LP if febrile without source / to rule out SAH(  @ 8 Investigations 3: Radiology American guidelines recommend emergency department head CT scanning in all cases In studies the incidence of CT abnormalities in adult  first-fitters varies widely (3-41%)  Predictors of abnormal CT scans in these patients lack sensitivity Over 20% of patients with an abnormal CT will have a normal neurological examinationGGF : Disposal 1: Admission More than one seizure (including status epilepticus) Incomplete recovery or prolonged postictal state Any patient with an identified aetiology requiring further investigation /treatment Patients with significant comorbidity "ZZT(   $   v    < Disposal 2: Discharge 0Young (<65) patients with an idiopathic seizure Neurology outpatient referral: details of relevant PMH, drugs/alcohol, witness details, examination and investigation results Advice: driving and the DVLA, vocation, leisure activities, first aid for relatives Is adult supervision necessary on discharge?110 = 6Disposal 3: The  grey area bPossible criteria for patient groups requiring observation +/- further investigation: Possible postictal symptoms on initial assessment (headache, nausea/vomiting, altered mental status) Focal neurology on initial assessment (should resolve if Todd s paresis) Should all patients be observed for a period?22(_    ?  References  Bradford JC, Kyriakedes CG. Emerg Med Clin North Am. 1999;17:203-20 Henneman PL, DeRoos F, Lewis RJ. Ann Emerg Med. 1994;24:1108-14 Jagoda A, Richardson L. Mt Sinai J Med. 1997;64:249-57                 4 //379;>@S ` 33PP` 13` 3333` Q_{` 333fpKNāvI` j@v۩ῑ΂H>?" dd@,?n<d@ `7 `2@`7``2 n?" dd@   @@``PR    @ ` ` p>> u m   (    <t{ L$"   "  TԂ{d L$"   "  <4{U_ L$"   "  T{d>& L$"   "  N{P L$"   "  <T{p L$"   "  C x{?d?bUv L$"   "   <t{    T Click to edit Master title style! !#" `$   0ԅ{    RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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Z\l[]kfEo___PPT10i.-@Z+D=' = @B +  (  r  S      x  c $ I   x  c $$    H  0޽h ? 3333___PPT10i.-t(+D=' = @B +}  $(  r  S d     r  S     H  0޽h ? 3333___PPT10i.-ؐ+D=' = @B +  *(  r  S d     x  c $    H  0޽h ? 3333___PPT10i.-0B:+D=' = @B +}  $(  r  S !     r  S      H  0޽h ? 3333___PPT10i.-0.v.+D=' = @B +   *(  r  S %     x  c $%    H  0޽h ? 3333___PPT10i.-$^+D=' = @B +}  @ $(   r   S T#     r   S #    H   0޽h ? 3333___PPT10i.-+D=' = @B +}  `($(  (r ( S d{     r ( S Ę{    H ( 0޽h ? 3333___PPT10i.-P< +D=' = @B +}  0$(  0r 0 S d{    { r 0 S ě{   { H 0 0޽h ? 3333___PPT10i.-pQ+D=' = @B + 0 F>(  X  C    >  S  0   Witness history  take details for neurology to contact at clinic. Seizure features  aura may be rising feeling from stomach, smell of odd scents. Tongue biting is a useful sign, incontinence of urine is not included. Partial seizures are less common but are important to recognise (higher incidence of recurrence and underlying aetiology).U H  0޽h ? 3380___PPT10.,`po 0 2*(  X  C    *  S d 0   >Syncope  up to 40% will have motor activity (tonic trunk extension + myoclonic jerks of the extremities), usually if left sitting Pseudoseizures  very difficult to differentiate from frontal-lobe seizures. Classically asynchronous movements of the extremities, forward pelvic thrusting, head-turning from side to side, and avoidance of noxious stimuli. Diagnostically do not develop metabolic acidosis or have raised prolactin levels. Cardiac arrythmias  includes long QT syndrome in young adults CVD  e.g. confusion with Todd s paresisjG   4        U H  0޽h ? 3380___PPT10.-{ 0 (  X  C      S  0   :Mandatory list  metabolic abnormalities are found in 5-8% cases (but low yield may be a type 2 error). Hypoglycaemia commonest (usually diabetic), then hyponatraemia. Pregnancy test (+urinalysis) in women of child bearing age to diagnose eclampsia. Additional list  evidence suggests FBC rarely, if ever alters management. Mg in alcoholics, malnourished, DKA, those on dialysis and diuretics. ECG if history suggestive of cardiac disease (long QT in young people). These investigations may be guided by clinical findings, however at least one study showed that abnormalities frequently occur (33%) in patients with normal physical and neurological examinations. >   J    H  0޽h ? 3380___PPT10.-x  0 TL (   X   C    L   S & 0   Studies on the incidence of abnormalities are both prospective and retrospective. They do not attempt to stratify the results by age Turnball et al. developed six predictors of abnormal CT scans in 82 patients with new-onset seizures: recent head trauma, abnormal neurology, multiple seizures, previous CNS disorder, focal seizure, and history of malignancy. These predictors had a sensitivity of 86% when tested on an independent group of 53 patients. Henneman et al performed a retrospective study of 333 patients. 134 of 325 (41%) had a  significant finding on CT of whom 30 patients had a normal physical and neurological examination. Significant = diagnosed aetiology of seizure or led to admission.>  ;   H   0޽h ? 3380___PPT10.-Äa  0 0q(  X  C      S " 0   s/Admission recommended in 46% in Henneman et al.(    H  0޽h ? 3380___PPT10.-PN U~  0 P$(  $X $ C     $ S  0   LIf CT available in A&E may not be necessary to admit older patients. DVLA advice  1 year off driving with medical review. Restored (until 70) if no further attack. Special consideration may be given if non-recurring secondary aetiology clearly evident. Driver s responsibility to inform DVLA and surrender license. May be worth getting patients to  sign to say they have received advice re. DVLA and vocation from us.(;   a H $ 0޽h ? 3380___PPT10.-pҵ  0 p,+(  ,X , C     , S { 0  { -Such patients should not necessarily be presumed to be postictal. 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