12e Seizure Expert Analysis Pt1 V2


Welcome back to this case
discussion on seizures. I have with me now,
Dr. Mahadevan, expert, who’s going to help us
review some of the questions that we addressed
earlier or put out there earlier in
the first video. Welcome. Looking forward to it. Thanks for having me. Of course. So let’s look at that first
video clip one more time. [VIDEO PLAYBACK] -This lady fainted
and is altered. What are we looking for? -Normal sinus. She’s not having an M.I. -Think about the differential. No ectopy. QT interval is not prolonged. QR restoration is 0.10. -Normal. Pupils equally reactive. What’s the common final
pathway in syncope? -Low blood pressure? I don’t hear a murmur -No. It’s the lack of vital nutrient
delivery to the brain stem reticular activating system. -Which is usually caused
by low blood pressure. -Or hypoxia, or hypoglycemia. Abdomen is soft and non-tender. [END VIDEO PLAYBACK] OK, so in my first
video, I had asked– because we see these two
physicians at bedside already, we don’t see them first
approach the patient –so my first question
was, how would you approach this patient, how
would you first come up to this patient,
what would you do, and what would you look for? Yes that’s very important. So the first steps again
in any sick patient: evaluate, think, act. So the approach
we’re going to take is, on arriving at bedside,
we’re going to evaluate. So the things that
we’re going to do are evaluate the patient’s
level of consciousness and their general
appearance, so that’s going to be the first thing. And looking at that
patient, eyes are closed, she’s not really
interacting with us, so that’s a little
bit concerning. Check the ABC’s,
if you’re dealing with an unconscious
patient, it becomes a CAB, so a quick
check of the pulse, evaluate the airway to make
sure that she’s breathing adequately, and then
if that’s all OK, get a set of vital signs. And we already
saw, they must have for some reason felt like
they wanted to give oxygen so they did even
act because she’s got some oxygen on
in the course there. Absolutely, absolutely. So we didn’t really get to see
them go through that process, but we’re kind of assuming
or hoping that they did that. Absolutely, before pontificating
with each other about what could be going
on, hopefully they took care of all
the things first. We’re assuming
they probably did. So next question, do you
feel that this patient is sick, or not sick? It’s always hard to tell, but
in this particular circumstance given that her eyes are closed,
she’s not really responding, they’re talking and we’re
not seeing anything from her, the assumption has to
be that she’s sick. I agree, we definitely
have to assume this patient is
sick, not responsive. So it looks like
she arrived maybe by ambulance or on
her own and nobody is around to provide
any information. How might you go about,
after you of course stabilize her, getting some
history on this patient? Yeah it’s always difficult
in patients like this, and again our first goal is
just to stabilize the patient, make sure that
they’re OK, they don’t need any immediate
interventions. It sounds like they did that. After that, you want to use
every means possible to try and obtain history, and that
might be sending another health care provider out, or
getting on the phone and trying to call family
members, or bystanders, or talk to EMS, or
call the nursing home or wherever the
patient may have been to get any additional
information, because it can be extremely valuable in
narrowing your differential diagnosis and identifying the
cause for this altered level of conscious. And checking the chart, maybe
she’d been there before. Absolutely, absolutely. Old medical records–
very, very useful. But this is a common
occurrence, so it’s something that we need to get
used to and deal with. Right, it happens all
the time and really crucial to get that information. OK, so what’s our next step? And you don’t necessarily
have to answer that, if you want we could
go on to the video. [VIDEO PLAYBACK] -So what are we ordering, kids? -CBC, lytes, head CT -And a urine tox screen. And call a family member to
verify she’s not on any meds. What medications cause
orthostatic hypotension? -Antihypertensives, Beta
blockers, dig, diuretics, phenothiazines, nitrates,
antidysrhythmics, antidepressants,
alcohol and cocaine. [END VIDEO PLAYBACK] So they’re still evaluating
this patient and, rightfully so, they’re kind of thinking about
this patient as a syncope or an altered mental
status, and they’re kind of talking about some
thoughts as far as differential and things they’re
going to order. So importantly, they’re kind of
going through their emergency medicine approach. So, they ordered a bunch of
things, well first of all, we see them– and this
isn’t a question to you –but we see them doing
their physical exam. Sure. They’re kind of discussing
their differential diagnosis, but what are–
they’re not putting some things on the
differential diagnosis, for example, seizure,
or postictal state. And then I’m sorry, so my
next question that I presented to the class was about
testing, and so you hear them ordering
a bunch of things like EKG, CT scan and some labs. Is there anything else
that you would order, that you don’t
hear them ordering? Sure. Yeah, this is tough
because you’re trying to do everything
simultaneously, sometimes you’re acting
before you have a chance to do your re-evaluation. Syncope and seizure could be
very difficult to differentiate between, especially
if you don’t have any history of the
loss of consciousness. So for sure, the
most important things in evaluating someone’s
syncope are the history, the physical exam
–those provide the vast majority
of information. And then the most
valuable diagnostic test is going to be an ECG, so
totally agree with that. In terms of if we’re
working up seizure, certainly there’s a
whole host of things that we can do that are
going to be important, but probably the
most important thing is to make sure that the patient
has a normal blood glucose, because that’s something
we could treat immediately at the bedside and
that would be something you don’t want to
get back from the lab and find out that
they’re hypoglycemic and that you’ve allowed
them to be hypoglycemic for an extend period time. The other things,
the important thing it sounds like they’ve
already addressed, is to make sure
they’re not hypoxemic. So check the pulse
ox, hypoxia, hypoxemia can cause seizures as
well, so you really want to ensure that they’re
oxygenated adequately. Those are going to be
the very first things. Beyond that, in
terms of studies, it sounds like they’ve
ordered a head CT. Clearly, if you’re worried
about a structural problem and someone with a seizure
or altered mental status CT would be valuable. Other labs would include
electrolytes, like the sodium, just to make sure that
they’re not hyponatremic and that’s not a reason for the
seizure, a urine tox screen, if that’s something
that you’re considering. Some patients who
are pregnant and it may be unbeknownst
to you could present with seizures and
preeclampsia or eclampsia once they start having seizures. So a pregnancy test would
be something to think about. If you’re worried about
meningitis or encephalitis, clearly doing a lumbar
puncture and obtaining some CSF would be important as well. And probably the most
important lab test that we get in
patients with seizures is actually, with
chronic seizures, is their anticonvulsant
level, and that is sometimes the only test that you need. You just get their
anticonvulsant level, if it’s low, you address
that and you’re done. You don’t really need
to get any other tests. Excellent. That’s great. Yeah I hear them saying
some of these things, but there are a number that
we don’t hear them verbalize, so that’s great to review. And I’m really glad you
brought up the glucose level, and again this
isn’t something you want to get on your chem panel. If anything check it
right when they arrive with their vital
signs, if you can. Absolutely. Yeah. So great. Let’s go on to the
next video then. [VIDEO PLAYBACK] -What happened? Where’s my daughter? -Your daughter’s
with your neighbor. My name is Dr. Pratt. You fainted at home, but
all your tests look good. We checked your heart,
your lungs, and your brain. You’re not anemic or dehydrated. And all your
electrolytes are normal. -I feel fine. -Are you taking any medication? -No. -Could be anything
over the counter– diet pills, cold medicine. -Nothing. -You ever have any heart
problems, palpitations, shortness of breath? -I’m healthy. -Anyone in your family
ever have seizures? -I did when I was a kid,
but I grew out of them. -How long ago was your last one? -I don’t know– years and years. I was on phenobarb
until like fifth grade. They said I had epilepsy. But when I stopped the
medicine, they went away. I never had another one. That was almost 20 years ago. -Dr. Pratt, can I
see you for a second? -Yep. Just give me a minute. -Can I go home now? -I need you now. -All right. I’ll be right back. -OK, I have a baby at home. -I just need to run
a few more tests, OK? Yeah. What’s up? [END VIDEO PLAYBACK] So in that last video, the
patient– appropriately the physician’s been at bedside
with this patient that’s sick and he’s not quite sure
what’s going on with her, and then she actually kind of
comes to and wakes up and so at that point, he’s
already thinking about his differential,
ordered some test, but now he can actually go
back and get a better history. So we hear him doing
that with the patient and getting some really
important history. And then I also, now
that she’s woken up, I presented in the
last video that I might redo my– at least
neurologic exam, and kind of reassess the patient. Sure. And the question
was presented, what are some findings
on physical exam that would be suggestive
that the patient did have a seizure, before
and after she wakes up. Not necessarily one
way or the other. Yeah. So one really
important thing is, whenever you’re
confused about what’s going on with the
patient, the answer is at the patient’s bedside. So I really applaud
this physician for going there, sitting
there, and waiting and getting the information. And you can go to the
patient as many times as you need to, to
get that information. So very well done on his part. What are some things that
help you differentiate syncope from seizure? It can be very tough,
as I mentioned, but there are few
things that would make you worry
more about seizure. And again, these are not perfect
but generally sort of direct you in that direction
towards seizure. One would be the presence
of tonic-clonic movements at the time that
they had their event. So if you see tonic-clonic
activity, especially for a prolonged period,
that suggests seizure. If the patient has
tongue biting, or urinary incontinence, these would
be two other clinical clues that this patient might
have had a seizure. Other things to
think about would be prolonged sort
of postictal state, so they have their seizure
and they don’t just come to when they
wake up, they are altered for a prolonged
period of time. That would also suggest seizure. And then retrograde
amnesia– they can’t really remember exactly
what happened, also would be suggestive of seizure. Again, these are clinical
findings on exam findings that are suggestive, but
not entirely diagnostic. Right, sometimes they don’t
present that clearly for you. But definitely
some good findings. OK, and again, he’s getting to
talk to her so that actually influences his differential
diagnosis, as well, and you can see that kind of
with the questions he’s asking. Absolutely. He really got some really
critical information, that she had a seizure disorder,
and she was on phenobarbital before and that
really put seizure high in the
differential diagnosis, especially given that we don’t
know exactly what happened. Which is really
interesting, and I like this case
because of this is, is that although we’re
hoping that postictal was on their differential for a
patient that comes in altered and unresponsive, however
you don’t necessarily hear them verbalize it. So she really does present
atypically for a seizure. They’re not really getting
most of this information except maybe this. So her waking up and
giving this history really changes what he’s thinking and
maybe what he’s going to order. And this happens all the
time in emergency medicine. You start out going
in one direction, you get more information,
and then you sort of shift. Certainly at the very beginning
in our differential diagnosis were seizure and syncope. Now we’re sort of
tending towards seizure.

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