5 - Seizures Flashcards
What are seizures?
- Vague term used to describe a variety of sudden, catastrophic events
- Synonyms: fits, Spells, Attacks
What are epileptic seizures?
- Typically result from abnormal electrical discharges in the cerebral cortex
- Caused from abnormalities in the Na/K/Ca channels in the brain (“channelopathies”)
- Generated by cortical neurons
- May be idiopathic or symptomatic
What are myoclonic seizures?
Myoclonic seizures are epileptic seizures that may have a sub-cortical focus
What is an EEG?
A way to measure electrical activity in the brain
Put receptors on the skull to read the electrical activity
A generalized seizure will look like big huge jumps (kind of looks like a fib)
What is epilepsy?
- Recurrent seizures (if you’ve only had one, you don’t have epilepsy)
- Means “to take hold of” in Greek
Describe the occurrence of epilepsy
- Common - affects 1-2% of the general population
- More common in females than males
- Overall incidence of seizures is higher (5% - any type of seizure)
- Increased incidence with developmentally delayed patients, psychosis patients, and people in the prison population
Describe the general functioning of epileptics
- 80% epilepsy patients function normally
- Only 60% of epileptic patients are free of seizures on medical therapy
- At least half of all patients report side effects from medications
What is an aura?
Aura – seizure prodrome, may be recalled by the patient
What is a convulsion?
Convulsion – motor manifestation of seizure
What is postictal state?
Postictal state – time from end of seizure to brain recovery
What is status epilepticus?
Status epilepticus – continuous (30 min or more) or recurrent seizures without waking up
Can be life threatening
Describe morbidity in epilepsy
- Recurrent seizures (seizures cause more seizures)
- Head trauma/body injury (falling, low glucose in brain during seizure, etc.)
- Social ostracism
- Learning/behavioral difficulties
- Endocrine problems (women particularly)
- Pregnancy problems
- Treatment side effects (many)
- Osteoporosis
- Death (SUDEP = sudden unexplained death in epilepsy)
- about 1% of epileptics (theory is cardiac death)
What are the two classifications of epileptic seizures?
- ILAE classification of epileptic seizures
- International classification of epilepsies and epileptic syndromes
What does the ILAE classification system depend on?
- Anatomical classification of the seizure
- Each seizure is a symtpom, not a disorder
- First you classify the seizure, then you look at it in the patient and cause
- Then you can look at the treatment options accordingly
What does the international classification system depend on?
Depends on localization of seizures and patient characteristics
What are the types of generalized seizures?
Generalized seizures affect both cerebral hemispheres A. Tonic B. Clonic C. Tonic – clonic (grand-mal) D. Absence (petit-mal) E. Myoclonic F. Atonic / Akinetic G. Infantile spasms
80% are partial or focal
20% are generalized
Describe the types of things you will see with each type of generalized seizures
A. Tonic (flexed)
B. Clonic (jerky)
C. Tonic – clonic (grand-mal) (both flexed and jerky)
D. Absence (petit-mal) (a generalized seizure which begins in kids, loose awareness for a few seconds, blinking, no tonic-clonic, may be repetitive (10-15/hour), only type that depends on an EEG to diagnose)
E. Myoclonic (when you’re drifting off to sleep and jerk - one is fine, many is a seizure, often part of another type of disorder such as hypoxia)
F. Atonic / Akinetic (born with a brain disorder - atonic they fall to the ground, akinetic they freeze)
G. Infantile spasms (slam the door and the baby freezes up and stiffens, bad sign)
What are the type of partial seizures?
- Partial simple (focal)
- Partial complex
- With secondary generalization
It stays on one side of the brain
Describe all the types of simple partial seizures you can have
- Motor
- Sensory (usually with motor - a “weird” feeling that is unrealistic)
- Autonomic (sweating, piloerection, usually with motor/sensory)
- Psychic (especially in temporal localized)
Describe partial complex seizures
Altered consciousness
- They don’t remember it
- They don’t lose consciousness, just altered
- Also have the motor, sensory, autonomic or psychic manifestations
Describe a partial seizure with secondary generalization
The important part is how this seizure begins
If it starts as a partial and goes general - this is what we call it
What is the third class of seizures?
Unclassified
We think they are having seizures, but we can’t find anything abnormal that can be identified
Once you classify the seizure, you take the information and put it together with the patient…
- Idiopathic
- Symptomatic
- Symptomatic/cryptogenic
How do we recognize seizure episodes?
- Episodic behavioral changes
- Stereotypy of events
- Automatisms
- Post-event confusion
- Episodes similar from event to event
- Non-directed behavior (there is not control over movement during a seizure)
- Recurrent, unexplained obtundation or confusion that resolve spontaneously over minutes or hours
Typically patients will have similar seizures each time with similar behaviors
What happens after a seizure
A period of time when the brain recovers (a few minutes up to 24 hours)
Typically confusion
What are the symptoms of convulsive seizures
- Single or multiple body jerks (myoclonus)
- Stiffening / posturing of part or whole body
- Jerking / twitching movements of part or whole body
- Sudden truncal flexion
- Drop attacks
- Tongue biting
- Bowel / bladder incontinence
What are the symptoms of non-convulsive seizures
- Altered awareness
- Staring, blinking
- Chewing, swallowing
- Picking at objects
- Repetitive movements
- Head or body turning
- Posturing of extremities
What types of symptoms suggest a behavioral event and not an epileptic event?
- Continuous aberrant behavior
- No post-event confusion
- Variable behavior
- Directed aggression
- Identifiable emotional trigger
- Secondary gain
- Not responsive to treatment (because it is not epilepsy)
What do you do in the patient workup for an epileptic evaluation?
Didn’t go over this
History and Physical exam
- Seizure onset / precipitating event
- Family history
- Trauma
Laboratory tests
- Blood chemistries, Lumbar Puncture
Brain Scan
- MRI, CT
EEG
What is the “first aid” protocol for seizures?
- Position patient
- Remove eyeglasses
- Clear harmful objects
- Loosen neck clothing
- Minimal restraint
- Turn on side
- Head dependent
- Nothing in mouth
- Secure airway (nasal tube)
- Observe until seizure over
- Call for help (prolonged seizure or repetitive seizures)
- Postictal reassurance
- No meds unless in status
What is the treatment for epilepsy?
- Prophylaxis (avoid head trauma/helmet)
- Treat causative factors (infection, temperature, intoxicant, etc.)
- Anticonvulsant therapy
- Dietary management (Ketogenic diet - 80% calories from fat)
- Surgery (seizure focus resection, brain stimulation, corpus callosum transection)
- Vagus Nerve Stimulator
- Psychosocial support
What are the therapeutic goals for epileptics?
- Complete seizure control
- Few adverse events
- Improved quality of life (not “just living” but life with meaning, relationships, and within the community)
- Affordable treatment
What are the principles of treating seizures in anticonvulsants
- Appropriate diagnosis*** (choose right med for patient/epilepsy/seizure)
- Lowest effective dose
- Switch meds if ineffective or unacceptable side effects
- Avoid polypharmacy if possible
- Monitor compliance, effectiveness and side effects
What are some side effects of anticonvulsants?
- Sedation
- Cognitive
- Behavioral
- Rash
- Weight gain / loss
- Hirsutism
- Hepatic toxicity
- Hematologic toxicity
- Teratogenesis
- Dizziness / Ataxia
- Tremor
- Nausea
- Hair loss
- Menstrual irregularities
- Diarrhea
- Peripheral neuropathy
Describe the drug interactions of anticonvulsants
- Influenced by absorption, protein binding, hepatic enzymes
- Increase of toxic effects
- Can actually cause seizures
- May lower levels of anticonvulsants
- Lower effectiveness of birth control, warfarin, etc.
What is the mechanical way to control seizures?
Vagus nerve stimulator
Describe the restrictions on driving?
- Patients with active epilepsy at risk for accidents
- Little risk with controlled or purely nocturnal seizures
- As safe as patients with uncontrolled Diabetes of Heart disease
- Epileptics are safer drivers than people with Obstructive Sleep Apnea
What are the restrictions in Iowa?
- Driving is a privilege, not a right - restriction for loss of consciousness
- 6 month seizure free period required to maintain driving privileges
Exceptions:
- No loss of consciousness, nocturnal / isolated sz
- Periodic physician statement
- No mandatory reporting
Describe the work and insurance problems that epileptics face
Work
- Might not be suitable for patients to drive, work with machinery and at heights
- May need time off to manage breakthrough seizures or chronic illness
- Need to deal with effects of seizures and medications
Insurance restrictions
- “Pre-existing conditions”
- Coverage for medications (generics)
- Epileptic clinics and advanced treatment option availability
Describe some of the specific problems that women epileptics face
- Endocrine problems (affect menstrual cycles, PCOD)
- Birth control ineffective
- Pregnancy concerns (seizures, teratogenesis)
- Breast feeding on anticonvulsants (less risk)
What happens if a woman wants to become pregnant and is an epileptic on anticonvulstants?
- Try to switch to anticonvulsant medications that have less risk of teratogenesis
- Some data is collected from a self reporting registry of birth defects
What are concerns with epileptics playing sports?
- Swimming
- Head trauma with various sports
- Heights / Gymnastics
- Effects of exertion on Seizures
- Coordination / cognitive effects of seizures and medications
