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Core clinical problems > 23. Seizure > Flashcards

23. Seizure Flashcards

1
Q

History taking seizure

A

PC:
HoPC:
- before: where were you? dizziness? light-headed? tunneled vision? nausea?, strange feeling? epigastric rising? deja vu? visual or smell disturbance?

  • during: memory of during? toung biting? incontinence? duration? movements?
  • after: recovery quick or slow? drowsy? weakness afterwards?

MHx:
syncope- Heart disease (arrhythmias) Peripheral neuropathy Drugs (that cause postural hypotension - e.g. diuretics, antipsychotics, antidepressants, antihypertensives)

seizure: recent infections?

space occupying: ever had cancer diagnosis (?mets)

DHx:
adherence if on anti-convulsants

FHx:
SHx:
syncope - Pain, heat, exertion, prolonged standing, emotion

seizure - Alcohol, sleep deprivation, bright lights, infections

Could you be pregnant?sexually active?

COLLATERAL HISTORY

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2
Q

causes of seizures?

A

Vascular: haemorrhagic stroke

Infectious: meningitis, encephalitis, systemic infection lowering seizure threshold, febrile seizures paeds

Trauma: head injury

Metabolic: Electrolyte disturbances: hyponatraemia, hypernatraemia, hypoglycaemia, hypocalcaemia, hypokalaemia, ammonia (hepatic encephalopathy)

Iatrogenic: tricyclic overdose, alcohol and benzodiazepine withdrawal

Neoplastic: space occupying lesion,

Environment: alcohol, stress, sleep deprivation

Functional: non-epileptic seizure
Pregnancy: eclampsia

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3
Q

what are breakthrough seizures

A

seizures that occur in known epileptics. These can be caused by poor medication compliance or precipitating factors such as sleep deprivation, alcohol and stress.

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4
Q

complications of prolonged seizures?

A

Airway:
Hypoxic brain injury due to airway occlusion and aspiration
Develop epilepsy after a prolonged seizure w hypoxic brain injury
Aspiration pneumonia

Injury:
Anterior dislocation of shoulder
Trauma and injury eg falling down stairs

Muscles contracting:
Electrolyte complications- lactic acidosis -
Creatinine kinase as a result of muscle breakdown - raised - rhabdomyolysis - kidney failure
Potassium intracellular so as muscles breakdown it is released - hyperkalaemia

Heart:
Arrhythmias

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5
Q

when should you treat a seizure?

A

Emergency treatment should be sought or given once a seizure has persisted, or there are serial seizures, for five minutes or more.

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6
Q

what is status epilepticus?

A

a single seizure lasting >5 minutes, or
>= 2 seizures within a 5-minute period without the person returning to normal between them

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7
Q

what should you consider as the cause for seizures first?

A

Rule out hypoxia and hypoglycemia before considering other causes

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8
Q

Assessment of prolonged seizure

A

ABCDE
Airway
Nasopharyngeal airway works well
Suction if anything visible
Recovery position if at risk of aspiration

Breathing
Oxygen
ABG may show metabolic acidosis (lactic acid from muscle contraction)

Circulation
At risk of
ECG monitor as at risk of CA and because of drugs you will use

Disability
GCS
Blood glucose!!

Exposure
Check for head trauma
PPting factors: acute illness, possible toxic exposure, trauma, recent heavy alcohol intake or cessation of chronic drinking, change in antiseizure medications

invetsigations
ABG (For acute prolonged seizures looking for hypoxia and hypercapnia)
Blood tests: FBC, U&Es (including serum calcium, magnesium and phosphate) LFTs, glucose
Urine test: urine toxicology screen
Imaging: CT Head

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9
Q

who should undergo RSI - rapid sequence endotracheal intubation and mechanical ventilation?

A

●Unprotected or unmaintainable airway
●Apnea or inadequate ventilation
●Hypoxemia
●Status epilepticus lasting ≥30 minutes
●Need to protect airway for urgent brain imaging (eg, in a patient with preceding trauma or signs of basilar territory stroke)

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10
Q

prolonged seizure treatment algorithim

A
  1. Benzodiazepine dose 1
  2. If still fitting after 10 mins, benzodiazepine dose
  3. Phenytoin or levetiracetam (keppra)or valproate
  4. If beyond 30 mins - Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. - rapid sequence endotracheal intubation and mechanical ventilation - thiopentone in fitting pt (has anti-seizure properties)
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11
Q

what benzodiazepine should you use in prolonged seizure algorithim in diff settings?

A

Pre-hospital buccal midazolam 10mg may be given by carers etc

Hospital setting w/o IV access - give rectal diazepam 10mg

Hospital setting w IV access - give 4mg IV lorazepam

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12
Q

benzodiazepine SE/risks

A

CNS depressive affects
resp depression

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13
Q

antidote benzodiazepines? works well for?

A

Flumazenil is antidote (selective competitive antagonist of the gamma-aminobutyric acid (GABA) receptor)

  • Flumazenil may be effective in reversing the sedation that occurs in a benzodiazepine overdose, but its effects on reversal of depressed breathing is less predictable.
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14
Q

Phenytoin considerations and dosing

A

20mg/kg loading dose
then 100mg every 6-8 hrs

DO NOT GIVE LOADING DOSE IF ALREADY ON PHENYTOIN - THEORETICAL RISK

It is Contraindicated in:
Second- and third-degree heart block; sino-atrial block; sinus bradycardia; Stokes-Adams syndrome, pregnancy
Ask if pregnant
Ask about medications and risk of CA
ECG monitor

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15
Q

What alternative drugs could you use if phenytoin is contraindicated?

A

Sodium valproate
levetiracetam (NICE says consider this 1st as less SE etc.)

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16
Q

what induction agent RSI fitting

A

thiopentone in fitting pt (has anti-seizure properties)

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17
Q

what is hypoglycaemia

A

Hypoglycemia occurs when glucose concentration falls below the normal fasting glucose level. Generally, this is defined as blood glucose levels below 3.3 mmol/L.

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18
Q

why are episodes of hypoglycaemia common in diabetic patients?

A

due to the variable response of blood glucose levels to their medications

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19
Q

symptoms of hypoglycaemia at different BG levels?

A

Blood glucose concentrations <3.3 mmol/L cause autonomic symptoms due to the release of glucagon and adrenaline (average frequency in brackets):

Sweating (66%)
Shaking (55%)
Hunger (44%)
Anxiety (27%)
Nausea (13%)

Blood glucose concentrations below <2.8 mmol/L cause neuroglycopenic symptoms due to inadequate glucose supply to the brain:

Weakness (50%)
Vision changes (42%)
Confusion (33%)
Dizziness (26%)

Severe and uncommon features of hypoglycaemia include:

Convulsion
Coma

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20
Q

management of hypoglycaemia

A

If the patient is alert, a quick-acting carbohydrate may be given (GlucoGel or Dextrogel).

If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.

Alternatively, intravenous 20% glucose solution may be given through a large vein

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21
Q

Presentation of acute alcohol withdrawal

A

symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety

peak incidence of seizures at 36 hours

peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

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22
Q

delirium tremens is characterised by?

A

agitation, confusion, paranoia, and visual and auditory hallucinations.

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23
Q

management delirium trmemens/alcohol withdrawal and seizures

A

alcohol withdrawal:
1. Chlordiazepoxide or diazepam in reducing regimen (long acting benzo)
2. Lorazepam if hepatic failure in reducing regimen
3. Carbamazepine

seizures
1. Lorazepam

delirium tremens
1. Lorazepam oral (fast acting benzo)
2. Lorazepam non-oral or haloperidol

Also give pabrinex if req (thiamine - vitamin b1)

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24
Q

what vitamin is thaimine

A

B1

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25
Q

typical presentation febrile seizures

A

typically occur in children between the ages of 6 months and 5 years

around 3% of children will have at least one febrile convulsion

usually occur early in a viral infection as the temperature rises rapidly

seizures are typically brief and generalised tonic/tonic-clonic in nature

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26
Q

management of eclampsia

A

IV magnesium sulphate

call obs, anaestheist, emergency theatres, neonatal intensivist etc.

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27
Q

typcial history generalised tonic-clonic seizure

A

There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements. Typically the tonic phase comes before the clonic phase. There may be associated tongue biting, incontinence, groaning and irregular breathing.

After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or low.

28
Q

what is a focal seizure

A

start in a specific area of the brain

may be impaired awareness or aware

29
Q

presentation focal seizure

A

motor or non-motor aura

motor- jacksonian march - spreads from the distal part of the limb toward the ipsilateral face. They involve a progression of the location of the seizure in the brain, which leads to a “march” of the motor presentation of symptoms.

non-motor: déjà vu, jamais vu

30
Q

another name for focal seizure?

A

partial seizure

31
Q

focal seizure temporal lobe features

A

HEAD

Hallucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)

32
Q

focal seizures - frontal lobe features

A

motor

Head/leg movements, posturing, post-ictal weakness, Jacksonian march

33
Q

focal seizures - parietal lobe features

A

sensory

paraesthesia

34
Q

focal seizures - occipital lobe features

A

visual

floaters/flashes

35
Q

Presentation absence seizure

A

Absence seizures typically happen in children. The patient becomes blank, stares into space and then abruptly returns to normal. During the episode they are unaware of their surroundings and won’t respond. These typically only lasts 10 to 20 seconds. Most patients (more than 90%) stop having absence seizures as they get older.

quick recovery; often many per day

36
Q

presentation atonic seizures

A

They are characterised by brief lapses in muscle tone. These don’t usually last more than 3 minutes. They typically begin in childhood. They may be indicative of Lennox-Gastaut syndrome.

37
Q

presentation myoclonic seizures

A

sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode. They occur in various forms of epilepsy but typically happen in children as part of juvenile myoclonic epilepsy.

38
Q

presentation non-epileptic seizure

A

Long duration > 10 minutes
Affective vocalisation
Ictal crying
Ictal eye closure
Side to side movement of head or body
Pelvic thrusting
Fluctuating course
Memory recall

history of trauma and/or mental health problems

39
Q

EEG absence seizure

A

3 Hz generalised, symmetrical

40
Q

presentation infantile spasms

A

Brief spasms beginning in first few months of life
1. Flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
2. Progressive mental handicap

usually 2nd to serious neurological abnormality (e.g. TS, encephalitis, birth asphyxia) or may be cryptogenic
poor prognosis

41
Q

presentation lennox-gestaut syndrome

A

May be extension of infantile spasms (50% have hx)
onset 1-5 yrs
atypical absences, falls, jerks
90% moderate-severe mental handicap

42
Q

diet for lennox-gestaut

A

ketogenic

43
Q

EEG infantile spasms

A

hypsarrythmia

44
Q

EEG lennox-gestaut syndorme

A

slow spike

45
Q

presentation benign rolandic epilepsy

A

paraesthesia (e.g. unilateral face), usually on waking up

46
Q

presentation juvenile myoclonic epilepsy

A

Typical onset in the teens, more common in girls
1. Infrequent generalized seizures, often in morning
2. Daytime absences
3. Sudden, shock like myoclonic seizure

47
Q

Investigation ?post first epileptic seizure

A

MRI can be used to identify any serious disorder that may have provoked the seizure, such as a brain tumour or arteriovenous malformation (a blood vessel abnormality).

electroencephalogram (EEG)

48
Q

When do you start treatment for epilepsy

A

Most neurologists now start antiepileptics following a second epileptic seizure.

unless:
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable

49
Q

what to consdier when choosing anti-epleptic

A
  • other medications antiepileptics can induce/inhibit the P450 system resulting in varied metabolism of other medications, for example warfarin
  • contraception both the effect of the contraceptive on the effectiveness of the anti-epileptic medication and the effect of the anti-epileptic on the effectiveness of the contraceptive need to be considered
  • pregnancy or wanting to get pregnant
  • breastfeeding
50
Q

Management generalised tonic-clonic seizures

A

men, girls under 10 unlikely to need in future, women unable to have children
1. sodium valproate

women and girls
1. lamotrigine or levetiracetam

51
Q

Management focal seizures

A
  1. lamotrigine or levetiracetam
  2. carbamazepine, oxocarbazepine, zonisamide
  3. lacosamide
52
Q

management absence seizures

A
  1. ethosuximide
  2. sodium valproate

sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy

53
Q

management myoclonic seizures

A

boys and men, girls under 10 unlikley need in future, women unable to have children
1. sodium valproate

women and girls
1. levetiracetam

54
Q

management tonic/atonic seizures

A

boys and men, girls under 10 unlikley need in future, women unable to have children
1. sodium valproate

women and girls
1. lamotrigine

55
Q

what seizures may carbamazepine exacerbate

A

absence and myoclonic

56
Q

risk benefit epilepsy management in pregnancy

A

The risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the fetus.

All women thinking about becoming pregnant should be advised to take folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects. Around 1-2% of newborns born to non-epileptic mothers have congenital defects. This rises to 3-4% if the mother takes antiepileptic medication.

57
Q

management of epilepsy in pregnancy

A

folic acid 5mg per day well before pregnancy

monotherpay - lamotrigine

58
Q

sodium valproate pregnancy associations

A

associated with neural tube defects

most common defect - hypospadias

significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.

59
Q

phenytoin pregnancy associations

A

cleft palate

60
Q

breastfeeding anti-epileptics

A

Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

61
Q

EEG benign ronldanic epilepsy

A

centro-temporal spikes

62
Q

management infantile spasms (wests)

A

prednisolone or vigabatrin

63
Q

indicators epilepsy > non-epileptic

A

Tongue biting and raised serum prolactin

64
Q

DVLA first unprovoked/isolated seizure

A

6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG.

65
Q

DVLA established epilepsy or multiple seizures unprovoked

A

may qualify for a driving licence if they have been free from any seizure for 12 months
if there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored

66
Q

DVLA withdrawal of epilepsy medication

A

should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose

67
Q

DVLA syncope

A

simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off

Core clinical problems (94 decks)

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