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Seizure due to Electrolytes Disturbances Dr. Nasser Haidar MRCP (UK), ABM, KSUF, PCCMF, FRCPCH Life Long Learning Slide 2 Introduction Body fluid and Electrolytes distrib. MgCa Na General outlines in electrloytes disturb. Electrolytes functions Summary Slide 3 40%15% 5% 60% of Body Weight Water 40% Solid Fat Proteins CHO Minerals Body Composition and Fluid Compartments Slide 4 K 100 Mg 123 Na 10 Na+ 142 K+ 5 Ca+ 5 Mg++ 2 Ph 149 Prot._ 55 HCO3 8 Cl 2 Cl 105 HCO3 24 Prot. 16 Phos 2 Sulfate 1 Total 154 Fluid Compartments and Electrolyte Balance Slide 5 K Neuromusc. Excitability Acid-B balance Mg++ Enzymes Na and Cl Fluid bal. Osmotic pres. Ca++ Bone Blood clot. HCO3- Acid-B balance Proteins Osmotic Press. Ph- Energy storage Sulfate Protein Metabo. Functions Slide 6 Daily Fluid Requirements InOut Slide 7 Routine lab. findingsClinical significance. Acute and/or severe Seizures Neurologic Serious complications Common in Na, Ca and Mg Rapid identification Prevent permanent brain damage Electrolytes Disturbances Slide 8 Regulation of ionic balance Ion gradients across cell memb. Consequences on brain metabolism and function Electrolytes Disturbances Epileptiform activities Disturbed Homeostatic brain systems Critical process Slide 9 Slide 10 Effects of Electrolytes Disturbances Functional reversible Seizure Structural (Irreversible) Slide 11 Na and osmolality Neuronal depression, with encephalopathy Neuronal irritability High Ca High Mg Low Ca Low Mg (Confusion and slight cognitive dist. ) Effects of Electrolytes Disturbances Slide 12 Generalized tonicclonic, other seizure occur. Not possible to assign absolute levels Seizure in Electrolytes Disturbances Slide 13 Electrolyte abnormality Frequency of seizures Hyponatremia ++ Hypernatremia++/+ Hypocalcemia++/+ Hypercalcemia+ Hypomagnesemia++/+ Hypokalemia Hyperkalemia Slide 14 Fast and Correct diagnosis of seizures With first-time seizures 375 adult cases of status epil.(SE), 10% had a metabolic disorder as the primary etiology of their seizure Anticipate in certain conditions 40% Slide 15 Treatment of the underlying cause Anticonvulsant not necessary Fast and Correct diagnosis of seizures Slide 16 The most prominent feature of the EEG slowing of the normal background Mixtures of epileptiform discharges, high incidence of triphasic waves (TWs), and (as a rule) reversibility after treatment of underlying causes Slide 17 Hyponatremia Slide 18 The cause of seizures in 70% of infants who lacked findings suggesting another cause HyponatremiaSlide 19 Extrarenal loss Renal loss RTASalt wasting DrugsAdrena. Hypovolemic Hypervolaemic Euvolemic Aetiology of Hyponatremia Slide 20 CNS pathophysiology Slide 21 Brain volume adaptation to Hyponatremia Equilibrium Fully adapted If hyponat. continued 48 hours Rapid adaptation 3 hours Might Be overcomed. Slide 22 Other factors influencing outcome Children Menestruant women Hypoxia and ischemia impair the brain adaptive mechanisms Concurrent insults [e.g., alcoholism or severe liver dysfunction ]. Slide 23 Carbamazepine Oxcarbazepine Valproate Lamotrigine Induction of excessive water re-absorption in the collecting tubule Antiepileptic drugs can cause Seizure Slide 24 Clinical features Severe or rapid (within hours). < 120 mEq/L usually around 110 mEq/L Ominous sign High mortality Stopped by rapid increases in Na only 3 to 7 mEq/L Slide 25 Further treatment with hypertonic saline may be unnecessary Further treatment with hypertonic saline may be unnecessary Maximum 5- 6 mL/kg of 3% saline bolus 5 to 6 mmol/L. Enough to stop sz Treatment Prompt 3% Quick decr. ICP Slide 26 120 - 125 mEq/L. 1 to 2 mmol/L/h Treatment 0.5 mEq/L/h Acute Chronic Target Slide 27 Osmotic Demyelination Syndrome (ODS) Rapid Correction of serum Na Osmolytes goes back slowly into cells Fluid loss from the neurons and glia Osmotic Demyelination S. with pontine and extrapontine demyelination + Slide 28 ODS quadriplegia, pseudobul. palsy, seizures, Coma, death. Demyelinating lesions may occur despite a careful correction of hyponatremia Complications Hypokalemia, hypophosphatemia, hypoxemia, and malnutrition with vitamin B defic. Hypokalemia, hypophosphatemia, hypoxemia, and malnutrition with vitamin B defic. Additional risks to demyelination Slide 29 Hypernatremia >145 mEq/L Slide 30 Seizure cause Hypernatr. Hypernatr. cause Seizure ? ? Slide 31 High Na intake Water deficit LossLow intake InsensibleAccidental salt intake Hypernatremia Confused Slide 32 Loss of water from brain cells CNS Pathopysiology Shrinkage of the brain Within minutes Moving electrolytes into cells. Few hours (rapid adap/) Intracellular accumulation of organic osmoly. (Slow adapta.) several days Encephalopathy Slide 33 Rupture of cerebral veins, focal intracerebral and SAH Values >180 mEq/L high MR, Acute (within hours) elevation to >158160 mEq/L Slowly increasing, to 170 mEq/L, well tolerated. Clinical presentation Rapid correction may lead to convulsions, coma, and death Slide 34 Normal saline in case of frank circulatory compromise, as volume expansion. Treatment Developed over hours. 1 mEq/L/h Chronic hypernatremia 0.5 mEq/L/h; Speed of correction depends on the speed of development Goal - replenish body water PO or NGT or IV Slide 35 Thus overly aggressive therapy carries the risk of serious neurologic impairment in chronic hypernatremia CNS Pathopysiology Slide 36 Hypocalcemia