Sd Convulsivo

Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

37

36IntroduccinDeben distinguirse los terminos crisis epileptica y epilepsia. Se define crisis epilpticacomo el resultado clinico de una descarga brusca, anormal por su intensidad ehipersincronia, de un agregado neuronal del cerebro; mientras que la epilepsia esun trastorno caracterizado por crisis epilepticas de repeticion.3Clasificacion Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

The most common generalized seizure type; typically seen in geneticepilepsy syndromes and in seizures arising from metabolic abnormalities(e.g., hyponatremia, alcohol withdrawal, medications, CNS infections). Begin with stiffening of the extremities (tonic phase), often associatedwith a guttural cry from contraction of the expiratory muscles, followedby rhythmic clonic jerking of the extremities. Associated urinary incontinence,5

Myoclonicseizures are characterized by frequent but asynchronous, nonrhythmicmultifocal myoclonic jerks. Myoclonic jerks are most commonly seenwith metabolic derangements (especially uremia) and are usually notEpileptic

6

The epilepsy type that can most resemble syncope clinically.Characterized by the abrupt loss of all muscle tone associated with a briefloss of consciousness. Primarily seen with inherited forms of childhoodepilepsy.7

Focal seizures in which no alteration of consciousness is noted.8

Evolve from simple partial seizures as the initial focal seizure activityspreads to involve some but not all of both cerebral hemispheres. Infact, the stereotypical warning or aura that many patients report is simplythe manifestation of the initial simple partial seizure. As seizure activity spreads, patients develop an impairment of consciousnessand behavioral arrest during which they display stereotypicalbehaviors known as automatisms (e.g., lip smacking, chewing,pulling at clothes). In contrast to simple partial seizures, complex partial seizures are associatedwith postictal confusion and lethargy.

9In many patients with prolonged complex partial seizures, seizure activitycan ultimately spread to involve the entire cerebral cortex. Themanifestation of the 2 generalization of the initial focal seizure activityis usually generalized tonic-clonic activity. Generalized seizures can thus be either 1 (generalized seizure activityat onset)10Patients with focal-onset seizures often have transient (minutes tohours) focal weakness or paralysis following seizure termination. Thisweakness usually involves the area of the body first affected by theseizure, providing an important clue to the focus of seizure onset. A patient with a generalized tonic-clonic seizure who is subsequentlynoted to have a postictal left hemiparesis likely had a focal-onsetseizure that began in the right hemisphere and secondarily generalized.11Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012Practically speaking, seizure activity lasting > 5 minutes is unlikely toremit spontaneously and carries the risk of permanent neuronal injury.

Generally,ongoing or recurrent seizure activity lasting > 5 minutes is thus considereda medical emergency and treated as status epilepticus.12

Some seizures are provoked,

Such patients are not considered to have epilepsy, because the presumption is that these seizures would not recur in the absence of the provocation.13Es Realmente Episodio Convulsivo?El paciente luego de un minuto y medio se levanta y se siente bien.sincope

Si el paciente estaba letargico, confundido luego de 20 min del episodio, entonces es convulsion

14No cada paciente que convulsiona tiene epilepsia15ETIOLOGIA

16Infecciones, encefalitis, meningitisVasculares, Stroke, Sangrado, MalformacionesStroke y luego convulsion---buscar factores de riesgo, deficit neurologico que nos indiquen un area deficituna px que empez con un dficit neurolgico y luego una convulsin, podemos pensar en ECV

INFECCIONES- pueden ser anaerobios, estrepto, gram negativo, infeccion mixta? biopsiasi HIV positivo y tenemos en la TAC una lesion en anillo.en historia, convulsiones y fiebre, cambio del estado de conciencia y convulsiona, paciente con fotofobia y aqu17Infecciones, encefalitis, meningitisVasculares, Stroke, Sangrado, MalformacionesTrauma, ToxicidadAutoinmune; VasculitisTraumaVino carlitos y quedo viendo libidinosamente a una chava, BUM le pega Diana con un bate y convulsiona, deprivacion de benzodiazepinas, cocaina, alcohol

Autoinmuneen la historia buscaremos si el paciente tiene rash, prpura y convulsiona, estigmas de LES y convulsiona, positiva ANA 18Infecciones, encefalitis, meningitisVasculares, Stroke, Sangrado, MalformacionesTrauma, ToxicidadAutoinmune; VasculitisMetablico (Na, Ca, Mg, O2, Glucosa) Metabolico---Siempre ver los electrolitos, oxigeno, puede el paciente tener hiponatremia con historia de confusion y depresion del estado de conciencia

-HipocalcemiaIn adults, hypocalcemia may occur after thyroid or parathyroid surgery or in association with renal failure, hypoparathyroidism, or pancreatitis. Typical prodromic symptoms and signs are mental status changes and tetanyIn adults, hypocalcemia may occur after thyroid or parathyroid surgery or in association with renal failure, hypoparathyroidism, or pancreatitis. Typical prodromic symptoms and signs are mental status changes and tetany.

Hipomagnesemia Magnesium levels below 0.8mEq/Lmay result in irritability, agitation, confusion, myoclonus, tetany, and convulsions

Hipoxemia,

Hipoglicemia,

Hiperglicemia: En el sistema nervioso central la hiperglucemia produce estrs, con liberacin de catecolaminas y la consecuente liplisis y liberacin de radicales libres causantes de estrs oxidativo en las neuronas.19Trauma, ToxicidadAutoinmune; VasculitisMetablico (Na, Ca, O2, Glucosa) IdiopticasNeoplasias Metablico (Na, Ca, Mg, O2, Glucosa) PsiquitricasInfecciones, encefalitis, meningitisVasculares, Stroke, Sangrado, MalformacionesNeoplasias---metstasis a cerebro, tumores primarios, examen neurologico focal

Psiquiatricas---

Porfiria, hipertiroidismo

20

Tratamiento

22

23

Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

24Agustn Julin Jimnez, Manual de Protocolos y Actuacinen URGENCIAS, Hospital Virgen de la Salud de Toledo (CHT) Tercera Edicin (2010)

25

26

27PLAN INICIALABC1o garantizar via aerea. Evitar broncoaspiracion. Monitorizar constantes vitales (TA, Ta, FC, FR, Sat O2, BMTest). Obtener via venosa (para muestra de bioquimica con niveles de calcio incluidos,hemograma, niveles toxicologicos y de farmacos). Gasometria arterial basal. Administrar 100 mg iv de tiamina, despues 50 ml de suero glucosado al 50%

1o garantizar via aerea. Evitar broncoaspiracion. Monitorizar constantes vitales (TA, Ta, FC, FR, Sat O2, BMTest). Obtener via venosa (para muestra de bioquimica con niveles de calcio incluidos,hemograma, niveles toxicologicos y de farmacos). Gasometria arterial basal. Administrar 100 mg iv de tiamina, despues 50 ml de suero glucosado al 50%(siempre administrar tiamina antes del suero).28Para Cortar CrisisLorazepam (0.1mg/kg)

Diazepam: 10-20 mg (ritmo de infusion 2-5 mg/min iv), maximo 20 mg.

4mg slowly into a large vein (diazepam 10mg is analternative). Repeat IV lorazepam 4mg slowly after 10min if seizurescontinue.0.1 mg/kg IV up to4 mg per dose, mayrepeat in 510 min29Para Tratar La Crisis Utilizar uno de los siguientes farmacos: Fenitoina: dosis inicial de 18 mg/kg (aprox. 1.000 mg), a un ritmo de 50 mg/mini.v y una carga maxima de 20 mg/kg. Valproato sodico: bolo inicial de 15 mg/kg en 5 minutos, y seguir con perfusioncontinua de 1 mg/kg/h (maximo 25 mg/kg/dia). Levetiracetam: 1.000 mg en 200 cc de suero salino a pasar en 30 minutos iv.(Dosis habitual 500-1.500 mg/12 horas iv).Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012Fenitoina y fosfenitoina son lo mismo, pero la fosfenitoina no causa hipotension 30Si No CedeFENOBARBITAL20 mg/kg IV con dosis adicionales 510 mg/kg

Anestesia GeneralMidazolam, Propofol

Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 201232BibliografiaGretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

33Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012

34

Gretchen M. Brophy Rodney Bel; Guidelines for the Evaluation and Management of Status, April 2012Tratamiento Pirimetaminay lasSulfamidas35