seizures/syncope

• Generalized tonic-clonic seizure


  Unresponsive, muscle twitching, tongue biting, urinary incontinence
• Tonic seizure


  Sudden stiffness or tension in the muscles of the arms, legs or trunk, commonly happens in sleep
• Clonic seizure


  Rhythmic motion of arms/neck/face
• Absence seizure


  Petit mal, blank out/stare into space
• Atonic seizure


  "Drop seizures" due to sudden loss of muscle strength
• Loss of consciousness (LOC) associated with seizure

  Episode of neuro dysfunction due to abnormal brain activity → sudden change in behavior/sensory perception/motor activity. Aura, focal symptoms, olfactory hallucinations, automatism (lip smack) before. Myoclonic jerks before LOC. 1-2 mins, BP/HR elevated, confusion after, horizontal deviation/flickering of eyes or blank stare, eyes open, lateral tongue biting.
• Loss of consciousness (LOC) caused by syncope

  Postdromal presyncope (feel like you're gonna pass out), palpitations, diaphoresis before. Myoclonic jerks AFTER LOC. Less than a min, maybe low BP/HR, rapid recovery. Vertical deviation (rolling back) of eyes, flickering eye lids. Eyes are closed or rolled back.
• Epilepsy


  2+ seizures are unprovoked by systemic illness/acute neurologic insult.
• Focused history and physical exam to evaluate seizure-like activity

  1. History: Characterize seizure, rule out differential diagnoses, underlying risks, onset abrupt? In relation to sleep? Twitch before? Meds? Cycle? Stress? Photosensitivity? Video games? Social ETOH or diet? Supplements?

  2. Physical exam: Not great but works for ruling out CNS infection/hemorrhage, related trauma from falls, tongue biting or incontinence... Neuro exam, joint dislocations. CNS infection signs: Febrile/toxic/petechial rash/nuchal rigidity, Brudzinski sign, Kernig sign.
• Differential diagnosis for seizure-like activity


  • Syncope
  • Migraines
  • TIA
  • Transient global amnesia
  • Panic attack
  • Paroxysmal disorders
• Appropriate laboratory and imaging for seizure-like activity

  1. POC glucose, CBC, CMP + mag, phos, hcg, UDS

  2. Lactate and prolactin (Hypothalamic stim) within first 2hrs

  3. Anti-seizure drug levels (ASD's)

  4. EKG to rule out cardiac causes

  5. Neuroimaging

  6. Lumbar Puncture (certain patients)

  7. Urgent vs routine EEG
• Syncope


  Impairment of normal vasoconstrictive response to moving into an upright posture
• Causes of syncope


  • Dehydration
  • Overheating
  • Moving positions fast
• Vasovagal syncope


  Nervous system does not regulate bp/hr correctly due to a stressor
• Vasovagal syncope mechanism


  1. Increased vagal firing at AV/sinus node

  2. Decrease heart rate

  3. Decrease sympathetic activity

  4. Decrease vascular tone

  5. Decrease preload/venous return/ventricular volume
• Carotid sinus hypersensitivity/post micturition syncope

  Enhanced vagal tone with resulting hypotension
• Cardiogenic syncope


  Due to mechanical/arrhythmic issues/ischemia or valvular abnormalities
• Cardiogenic syncope has no symptoms before, so has a greater risk of injury
• Causes of cardiogenic syncope

  • Family history
  • Personal history of arrhythmias
  • Prolonged QT
• Symptoms of syncope


  • Muscular weakness
  • Blurred vision
  • Feeling faint
  • Nausea
  • Sweating
  • Increased heart rate
  • Pallor
  • Lightheadedness
  • Weakness
• Diagnosisof syncope


  • ECG
  • Autonomic testing (for vasovagal syncope)
• Treatments for syncope


  • Avoid stimuli
  • Tilt training
  • Increase fluid/salt intake
  • SSRI
  • Pacemaker