Emergency medicine problem 3

Kevin sitorus 405090118

Seizure
Seizure is defined as abnormal neurologic functioning caused by abnormally excessive activation of neurons, either in the cerebral cortex or in the deep limbic system. Epilepsy is defined as recurrent unprovoked seizures due to a genetically determined or acquired brain disorder

Classification and Epidemiology

DISORDERS OF CONSCIOUSNESS

Physiology of Consciousness
Depends on Intact and Interacting Brainstem Reticular Formation and Cerebral Hemisfer

Physiology of consciousness

Pathogenesis
Dysfunction of the Ascending Reticular Formation in The Thalamus or Brainstem, and/or Dysfunction of Both Cerebral Hemisfer

Pathogenesis
Supratentorial Lesions Infratentorial Lesions

GLASGOW COMA SCALE

Eye Opening
Spontaneously To Speech To Pain None 4
3 2 1

Glasgow Coma Scale

Motor Response
Obeys Command Localize Pain Flexion Withdrawl Flexion Abnormal(Decorticate) Extension (Decerebrate) No Response 6 5 4 3 2 1

Glasgow Coma Scale

Verbal Response
Oriented And Converses Disoriented Inappropiate Words Incomprehensible Sounds No Response 5 4 3 2 1

Classification of Levels of Consciousness

Normal Consciousness Confusion Delirium Obtundation Stupor Coma

Etiology
Supratentorial (15 %) and Infratentorial (15%) Lesions Brain Hemorrhage (Intraparenchymal, Subdural, Subarachnoid) Brain Infarction Venous-sinus Thrombosis

Etiology
Meningo-encephalitis Brain Abscess Brain Tumor Head Injury

Etiology
Diffuse Brain Disturbances (70%) Metabolic: Hypoxia Hyponatremia Hypoglycemia Hyperglycemia Uremia

Etiology
Liver failure Hypocalcemia and hypercalcemia Hypothyroid Thiamine deficiency

Status Epilepticus

DEFINITION
Prolonged seizure activity lasting greater than 30 minutes Or, recurrent seizures without the interval of recovery (consciousness) lasting greater than 30 minutes

Etiology
The main causes of status epilepticus are low blood concentrations of antiepileptic drugs in patients with chronic epilepsy (34%) remote symptomatic causes (24%) cerebrovascular accidents (22%) anoxia or hypoxia (~10%) metabolic causes (~10%), and Alcohol and drug withdrawal (~10%)

Pathophysiology
Phase 1 : electrical discharge of abnormal cerebral cells Increased metabolic demand increased arterial blood pressure and autonomic activity arterial BP, blood glucose, Sweaty, Hyperpyreksia, salivation. Phase 2 (30 minutes after Phase 1) : characterized by a failure of cerebral autoregulation, decrease cerebral blood flow, increase of intracranial pressure and systemic hypotension decrease of cerebral perfusion.

General Convulsive Status Epilepticus

GCSE is usually diagnosed easily by observation alone characterized by Unconsciousness tonic-clonic muscle activity tongue biting and urinary incontinence.

 Nonconvulsive status epilepticus Convulsive status epilepticus may evolve into the nonconvulsive form after treatment characterised by abnormal mental status with unresponsiveness, ocular motor abnormalities, persistent electrographic seizures and possible response to anticonvulsants. It may also arise de novo, and this possibility should be kept in mind while making a diagnosis. - All patients with prolonged postictal confusion or unexplained coma should undergo EEG monitoring for confirmation.

Diagnosis
Medical history: Anti convulsion drug, drug overdose, stroke, CNS Infection. Physical examination:
Complete neurologic examination (GCS, Meningeal sign , pupil reflects, etc) Negative and positive symptoms Focal Neurological deficit

ElectroEncephaloGram (EEG) Imaging (CT-scan, MRI) Lumbal Punction

DD
1. Movement disorder : Myoclonic, tremor, chorea, tics, dystonia. 2. Limb Shaking transient ischemic attacks (TIA) 3. Psychogenic disorder : psychogenic nonepileptic seizure, acute psychotic, catatonic.

Protocols of status epilepticus

Complication
CNS (cerebral hypoxia, cerebral edema, cerebral hemorrhage) Cardiovascular system (myocardium infarct, arrhythmia, cardiac arrest) Respiratory system (aspiration pneumonia, pulmonary hypertension, pulmonary embolic) Metabolic changes (dehydration, electrolyte change, acute tubular necrosis)