emergency management in chronic neurologic disease
DESCRIPTION
Tipa Chakorn, M.D. Faculty of Medicine, Siriraj HospitalTRANSCRIPT
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Emergency Management in Emergency Management in Chronic Neurologic DiseaseChronic Neurologic Disease
Tipa Chakorn, M D . Faculty of M edicine, Siriraj
H ospital
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Chronic neurologic disease
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หญ�ง 48 ป� พดค�ยร�เร��อง ม�อาการล�กษณะน��คร��งแรก
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Provoked factor
• Metabolic: hyper-hypoglycemia, hyponatremia, hypoxia• Drug withdrawal: AEDs, Sedative drugs (BZDs, Alcohol)• Drug intoxication: Aminophylline, TCA
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• Unprovoked seizure• Clinical diagnosis– Partial seizure: simple partial seizure, complex partial
seizure– Generalized seizure: GTC, Tonic seizure, Clonic
seizure, Myotonic seizure, absence etc.
• Investigation: Imaging, EEG• Treatment
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Common Errors in Diagnosis
• Failure to get a good detail history• Syncope, movement disorder, psychogenic• First identified epileptic seizure may not be
the first seizure• Seizure type: GTC, Complex partial seizure,
Absence
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Investigation
• EEG: Less sensitive, more specific– Sleep deprivation: increase sensitivity– VDO monitored EEG: increase sensitivity
• Imaging: Recommended in late onset epilepsy– Partial seizure/localization related epilepsy– Normal imaging does not mean normal brain–MRI is better than CT
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Consideration in the treatment of a first unprovoked seizure
• 1/3-1/2 of patient with seizures will present following a single seizure1
• 10 to 12% of the first unprovoked seizure will be status epilepticus2
• Recurrence rate after a first seizure is 27 to 52%3
1. National General Practice Study of Epilepsy. Lancet 1990;336:1267–12712. Guidelines for epidemiologic studies on epilepsy. Epilepsia 1993;34:592–596
3. Pediatrics 1990;85:1076–1085
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Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures:
A randomised controlled trial
Lancet 2005; 365: 2007–13
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Lancet 2005; 365: 2007–13
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Risk of recurrence
• Age of onset• Duration of the initial seizure in children• Multiple seizures at first seizure presentation• Abnormal EEG• Being asleep during a first seizure in children• Seizures that occur at night in adults
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Risk of treating
• Adverse side effects: idiosyncratic• Chronic toxicity: cognitive and behavioral
effects, bone loss, neuropathy• Teratogenicity effect• AED therapy implies chronic illness
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Risk of not treating
• Treatment will reduce risk of recurrent seizure by 50%
• Serious injury from brief seizure: driving, riding, swimming, cooking
• Psychosocial impact: loss of driving privileges• Social stigmata
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Seminars in neurology 2008
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Anti-epileptic drugs
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Anti-epileptic drug and seizure type
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ชาย 40 ป� ช�กเกร!งกระต�ก 30 นาท�ก$อนมาโรงพยาบาล ช$วงเกร!ง
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ไม$ร�เร��อง ไม$เคยม�อาการเช$นน��มาก$อน 1. Emergency condition? (consciousness, A, B, C)
2. Seizure?
3. Investigation?
4. Treatment: AED? (IV or oral route)
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Parenteral doses VS. oral doses
• New onset epilepsy with – Stroke with brain edema– Brain tumor with edema– Acute infectious process: encephalitis, meningitis,
brain abscess
• Depend on type of seizure, comorbid medical• Unnecessary use of high dose: increases
adverse event
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ชาย 40 ป� ช�กเกร!งกระต�ก 30 นาท�ก$อนมาโรงพยาบาล ช$วงเกร!ง
กระต�กนาน 4-5 นาท� หล�งช�กม�ป(สสาวะราด เร�ยกล�มตา แต$ย�งพดค�ย
ไม$ร�เร��อง เป+นโรคลมช�กอย$เด�ม ก�นยา Phenytoin 300 mg/day
เคย CT brain แล�วปกต�
1. Emergency condition? (consciousness, A, B, C)
2. Seizure?
3. Investigation?
• No provoked factor
• Phenytoin level 10.5 mg/dL
• Treatment: Increase dose VS. add second line drug
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Serum concentration of AED
• Therapeutic range • Best seizure control and absence of adverse
events• Blood level of highly bound to albumin AEDs:
Phenytoin
Hypoalbuminemia Increased free fraction
C adj = Creported /(0.2 x serum albumin) + 0.1
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If the first AED fails
• Due to lack of tolerability:
• If the first AED is totally ineffective:
• If the first AED is incompletely effective
substitution monotherapy
Replace AED
Adjunctive therapy
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หญ�ง 48 ป� พดค�ยร�เร��อง ม�อาการล�กษณะน��คร��งแรก
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• Diagnosis: Partial seizureEpilepsia partialis continua
• Investigation: Blood sugar etc.• Imaging• Treatment
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Childbearing Potential and Pregnancy Patient
• Valproate: alter endogenous steroid– Associated with higher risk of polycystic ovaries– Does not interfere with oral contraceptives– Highest risk of malformation
• Topiramate/oxcarbazepine reduce oral contraceptive efficacy
• Lamotrigine: not associated with overall birth defect
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Movement Disorder
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Movement disorder
• Hypokinetic movement– Parkinson’s disease– Parkinsonism
• Hyperkinetic movement– Tremor– Chorea– Dyskinesia– Dystonia
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Abnormal movementEXCESS MOVEMENT
No
Bradykinesia
Cognitive, language, upper motor neuron, or sensory signs
Only cogwheel rigidity or rest tremor
Rhythmical
Yes
YesNo
Slow or sustained
Rapid
Athetosis or dystonia
Tremor
PosturalParkinsonism
RestIntention
Controllable UncontrollableMetabolic, essential or enhanced physiologic
Cerebellar or brainstem Tic
Distal Proximal Multifocal
Chorea Ballismus Myoclonus
Degenerative disease with parkinsonism
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Parkinsonism
• Bradykinesia• Tremor• Cogwheel rigidity• Postural instability
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Idiopathic Parkinson’s disease
• Age > 55 years• Unilateral disease• Involve upper part > lower part• Response to Dopamine treatment• Normal cognitive function
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Parkinsonism
• Drug-induced (Neuroleptics drug, antiemetics)
• Toxic-induced (CO, Mn)• Vascular parkinsonism• Normal pressure hydrocephalus• Wilson’s disease
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• Review history of drug and toxin exposure• Family history• Neuroimaging: post stroke, NPH, etc• Slit lamp examination• Laboratory: – LFT, serum ceruloplasmin, 24 hr urine copper
excretion (Wilson’s disease)– Serum calcium, phosphorus, parathyroid (for bilateral
basal ganglia calcification)– Lumbar puncture (in selected cases eg. Suspect
chronic infection, NPH)
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Imbalance primarily between the excitatory neurotransmitter and inhibitory neurotransmitter in the Basal Ganglia
AChDA
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Wearing off
• Stiffness• Full consciousness: awake• Relate with L-dopa treatment
Delayed on
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Peak dosed dyskinesia
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Abnormal movementEXCESS MOVEMENT
No
Bradykinesia
Cognitive, language, upper motor neuron, or sensory signs
Only cogwheel rigidity or rest tremor
Rhythmical
Yes
YesNo
Slow or sustained
Rapid
Athetosis or dystonia
Tremor
PosturalParkinsonism
RestIntention
Controllable UncontrollableMetabolic, essential or enhanced physiologic
Cerebellar or brainstem Tic
Distal Proximal Multifocal
Chorea Ballismus Myoclonus
Degenerative disease with parkinsonism
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Hyperkinetic movement
• Tremor– Resting tremor– Postural tremor– Action tremor
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• Physiologic tremor• Essential tremor• Drug-induced tremor: TCA, Lithium etc.• Metabolic disorder: thyrotoxicosis,
hypoglycemia, pheochromocytoma
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Abnormal movementEXCESS MOVEMENT
No
Bradykinesia
Cognitive, language, upper motor neuron, or sensory signs
Only cogwheel rigidity or rest tremor
Rhythmical
Yes
YesNo
Slow or sustained
Rapid
Athetosis or dystonia
Tremor
PosturalParkinsonism
RestIntention
Controllable UncontrollableMetabolic, essential or enhanced physiologic
Cerebellar or brainstem Tic
Distal Proximal Multifocal
Chorea Ballismus Myoclonus
Degenerative disease with parkinsonism
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Dystonia
• Abnormal posture of one or more portion of the body
• Stereotyped
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• Dopaminergic drugs• Anticholinergic drug• Benzodiazepine• Baclofen• Anticonvulsant• Botulinum toxin
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Abnormal movementEXCESS MOVEMENT
No
Bradykinesia
Cognitive, language, upper motor neuron, or sensory signs
Only cogwheel rigidity or rest tremor
Rhythmical
Yes
YesNo
Slow or sustained
Rapid
Athetosis or dystonia
Tremor
PosturalParkinsonism
RestIntention
Controllable UncontrollableMetabolic, essential or enhanced physiologic
Cerebellar or brainstem Tic
Distal Proximal Multifocal
Chorea Ballismus Myoclonus
Degenerative disease with parkinsonism
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Chorea
• Nonstereotyped, free flowing movement• Random in space
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Tardive dyskinesia
• Mixed dystonia & chorea• Abnormal movement devolop in some
patients receiving long term treatment with DA blocking agent
• Most frequently: Orobuccolingual dyskinesia
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VDO clip
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• Trihexyphenidyl• Clonazepam• Baclofen• Reserpine• Botulinum toxin
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EXCESS MOVEMENT
No
Bradykinesia
Cognitive, language, upper motor neuron, or sensory signs
Only cogwheel rigidity or rest tremor
Rhythmical
Yes
YesNo
Slow or sustained
Rapid
Athetosis or dystonia
Tremor
PosturalParkinsonism
RestIntention
Controllable UncontrollableMetabolic, essential or enhanced physiologic
Cerebellar or brainstem Tic
Distal Proximal Multifocal
Chorea Ballismus Myoclonus
Degenerative disease with parkinsonism
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Thank you