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An episode of abnormal neurological function caused by an inappropriate electrical discharge of brain neurons
A seizure in which conciousness and mentation are not affected
A seizure in which consciousness and/or mentation are affected
A seizure with wide spread electrical discharge, Loss of conciousness, often accompanied by tonic clonic movements tounge biting and incontinence
What should you do on PE after a seizure? (3)
- Injuries- head and spine and musculoskeletal injuries, also lacerations (dont forget the mouth for tounge biting)
- Neurological examination (Todd paralysis, transient focal deficiet)
- Bedside glucose
What is Todd paralysis?
Foacalized weakness if this is present you should worry about stroke or TIA
Why should you perform serial neurological exams in a pt who has had a seizure?
Post ictal time will have changing neurological status
What is the first question for a pt or bystander presenting post seizure?
Was it a seizure
What characteristics does syncope have that seizures do not
preceeded by dizziness, diaphoresis, usually no post ictal symptoms
What are 4 differential diagnoses to seizure?
- movement disorders
What are 4 features of a seizure that set it apart from syncope?
- Abrupt onset and termination
- Lack of recall
- Movement during attack is inappropriate and purposeless
- Most followed by lethargy and confusion (postictal state)
State of lethargy and confusion that follows a seizure
post ictal state
What are some things that could cause a patient with a known seizure to have an attack?
Missed dosage, change in medication, change in dosage, sleep deprivision, infection, alcohol
___ is a drug used for depression and for smoking cessation that lowers the threshold for seizures to occur
What labs do you order for a pt who has a history of seizure disorder that has just had an acute attack?
You may not need to get labs but you should check the level of anticonvulsant in their blood if you didn't give them any if their levels are low you should get either their perscribed medication on board or get phenytoin 10-20 mg/kg loading dose
You have a pt who has a past history of seizure disorder who ran out of their anticonvulsant medication. They had a seizure and were taken to the ER for care you quickly ruled out any trauma prior to or after the seizure. After the post ictal period you administer 10mg phenytoin can you discharge this patient?
Yes, you should have them go home with someone else and instructions to follow up
Name some secondary causes of seizure
- head trauma
- intracranial hemorrhage
- structural abnormalities
- metabolic disturbance
- anoxic ischemia injury
- hypertensive encephalopathy
What labs/imaging should you order for a pt with a first time seizure event?
- Labs: cbc, complete metabolic pannel, urinalysis, mg, toxicology screen, pregnancy
- CT head no contrast or MRI
- neurological consult
Why would you order a pregnancy test for a first time seizure pt?
Eclampsia can cause seizures
Do you need a patient's permission for a toxicology screen?
______ is continuous seizure activity for 30 or more minutes or tow or more seizures that occur without full recovery of consciousness between attacks
How long should you wait before intervening in a seizure?
5 minutes of seizure time
What labs would you order on a Status epilepticus patient?
Large bore IV, bedside glucose (tx hypoglycemia with glucose and thiamine), intubation, foley, NGT, Labs, cardiac Monitoring, EEG monitoring
You have a patient in status epilepticus who you have to give paralytics to. Why do you need to get an EEG on this patient?
If they are a tonic clonic seizure and you paralyze them, then the EEG is the only thing that can tell you if they are continuing to seize
What medication do you start with for a patient with status epilepticus?
What do you give a status epilepticus patient if they cannot have lorazepam?
Diazapam (valium) and phenytoin
If the first line treatments for status epilepticus are not working what do you give next?
If you have a patient in status epilepticus for 30 minutes what do you give?
- General anesthesia
- admission to the ICU
What are the ACEP guidelines for neuroimaging in the ED?
- New focal deficit
- persistent altered mental status
- recent head trauma
- first seizure
- coagulapathy/anticoagulation therapy
- HIV positive/immunosuppression
- Change in seizure pattern
What are the ACEP recommendations for neurology consult?
- New seizure
- abnormal neurological examination
- perisitent AMS
- new intracranial lesion
- change in seizure pattern
- poorly controlled seizures
- pregnant patient
Who gets admitted to the hospital ACEP recommendations
- persistent AMS
- CNS infection
- New focal abnormalities
- new intracranial lesions
- underlying correctable medial problem
- acute head trauma
- status epilepticus
4 things you should do if you are in the hospital and a pt begins to seizure
- protect the patient from injury
- if you can turn the patient to one side to prevent aspiration
- watch and wait
- Lorazepam (ativan) (not for uncomplicated seizure)
T or F lorazepam helps prevent another seizure after the first if administered to a pt having a seizure
T or F lorazepam does not prolong the post ictal state
3 situations that you want to advise your patient to be cautious with after a seizure or with a propensity to seizure
- working at tall heights
- operating machinery
Hypoglycemia is a serum glucose that is less than ________
What are some conditions that can result in hypoglycemia
DM, sepsis, liver disease, alcohol intoxication, certain toxic agents
Two diabetic drugs that can cause hypoglycemia and mean the patient should be admitted
insulin and sulfonylurea (OHA)
Which insulin medication may or may not cause hypoglycemia
Which three DM meds do not cause hypoglycemia
- alpha glucosidase inhibitors
What are some neuroglycopenic manifestations of hypoglycemia?
What are some hyperephinephrinemic symptoms of hypoglycemia
anxious, irritability, N/V, palpitations, Tremors
ANYONE who presents with AMS should have what test done?
Bedside glucose check
What is the best treatment for hypoglycemia?
Oral replacement. Orange juice, or glucose tabs or a candy bar
What is the problem with amp D50 for hypoglycemia?
You need IV access
Can you give Glucagon to an alcoholic with hypoglycemia? Why or why not?
NO. in alcoholics and other people with depleted glycogen stores hypoglycemia will not improve
If you have a pt with hypoglycemia who has had oral glucose therapy and is not responding what can you give them next?
When should you admit a hypoglycemia patient?
- DM pts on long acting insulin and sulfonureas
- recurrent hypoglycemia/ recurrent AMS
- Precipitating factors (sepsis)
- Lack of follow up, or supervision
45 y/o female presents via ambulance for AMS, when she was found she had a finger stick of 30 given amp D50 with resolution of symptoms. Pt med hx: dm metformin, afebrile and normal vitials should you adimit her or discharge her?
33 y/o pt presents after having AMS per friends. Arrived via EMS. Pt had glucose level 50 at site picked up and was administered amp D50 pt is on long acting insulin. Should you admit this patient or discharge them?
Admit (they are on long acting insulin)
A severe systemic hypersensitivity reaction characterized by multisystem involvement. This can include airway and cardiovascular compromise
What are the 3 most common causes of anaphylaxis
- Insect bites
A pt presents to you with diffuse urticaria and angioedema what do they have?
pt presents with a �lump� in their throat which is causing nausea and vomiting and shortness of breath what emergent condition is on your differential?
What are some clinical manifestations of anaphylaxis
- diffuse urticaria and angioedema
- abdominal pain
- lump in throat or hoarsness
- chest tightness
What do you need to consider in any patient with acute respiratory distress, bronchospasm, hypotension or cardiac arrest?
What is first thing you do with a patient who is in acute respiratory distress from anaphylaxis?
Secure the airway
with suspected anaphylaxis what do you give?
If you have a pt with anaphylaxis who you have given epi, but they still remain hypotensive what should you give next?
Normal saline bolus
Name a second line therapy for anaphylaxis
- glucagon � if the patient is on beta blockers then they will be refractory to epinephrine you need to give these patients glucagon for anaphylaxis
what do you need to give a patient with anaphylaxis who is on Beta blockers?
Glucagon because they will be refractory to epi
How long do patients who have received epi need to be monitored
at least 4 hours
If you have an unstable anaphylaxis can you d/c that patient?
No you should admit
What anaphylactic patents besides those that are unstable should you consider admission?
Asthmatic, social issues, comorbidities, age
If a pt is on a beta blocker and has an anaphylactic response to peanuts can they return to their beta blocker? If so how soon?
NO they should be switched off beta blockers and given an emergency epi pen
When d/c an anaphylaxis patient medications should they be prescribed?
- Prednisone 40-60 mg per day 3-5 days
- Diphenhydramine and an H2 blocker
your pt w/ a history of asthma has dyspnea wheezing, cough, chest tightness, and a prolonged expiratory phase what do you think they have?
Mr. Smith has a history of asthma, presents using accessory muscles cant catch his breath to speak, HR 120, O2 sat 88 % RR30 what treatment would you suggest
What do you give an acute asthma exacerbation first line?
22 y/o with past medical hx of asthma presents with exacerbation brought on by the cold weather. VS nl, pk flow 250 pt speaking in full sentences with diffuse wheezing what do you perscribe?
- Albuterol nebulizer and O2 via nasal
- possibly nebulized prednisone do another peak flow later
35 y.o. Male presents with acute asthma pk flow 100, pt cannot speak and has a quiet chest what should you do?
56 y.o. Male presents with crushing chest pain substernal with radiation to chest, jaw and left arm. He is also short of breath and states the pain is a 10/10 with no relief from rest what does he have?
Ischemic chest pain prolly an MI
Protocol says that if a pt is 30 yrs or older with chest pain they should have an EKG within ___ minutes from entering the ED
How do you tell the difference between a STEMI and a NSTEMI?
What do you treat a STEMI with?
- ASA, ntg, morphine, O2
Chest pain that is unresolved even w/out being an NSTEMI (should/should not) be admited
ADMIT it may evolve into an MI cath in the morning