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N - C > Blackoutd, First Seizures and Epilepsy > Flashcards

Blackoutd, First Seizures and Epilepsy Flashcards

1
Q

What is the Differential diagnosis in someone who has presented with a blackout?

A 
Syncope
First seizure
Hypoxic seizure
Concussive seizure
Cardiac arrhythmia
Non-epileptic attack
-Narcolepsy
-Movement disorder
-Migraine
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2
Q

How can you tell the diagnosis from a blackout?

A

Detailed history from the patient
Detailed history from witness

(tests)

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3
Q

What should you try to get from the history of a patient with blackout?

A

What were they doing at the time?
What, if any, warning feelings did they get?
What were they doing the night before?
Have they had anything similar in the past?
How did they feel afterwards?
Any injury, tongue biting or incontinence?

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4
Q

What should you try to get from the history of a witness to a blackout?

A

Detailed description of observations before and during attacks -including level of responsiveness, motor phenomena, pulse, colour, breathing, vocalisation

Detailed description of behaviour following attacks

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5
Q

What is some additional potentially relevant information you may want to obtain about a blackout patient?

A 
Age
Sex
PMH including head injury, birth trauma and febrile convulsions
Past psychiatric history
Alcohol and drug use
Family history
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6
Q

What is Psycogenic Non-Epileptic Seizures (PNES)?

A

These seizures are caused by psychological trauma or conflict that has a lasting effect on your state of mind.
Sexual or physical abuse is the leading cause of psychogenic seizures, where the abuse occurred during childhood.

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7
Q

What is Vasovagal Syncope

A

One of the most common causes of fainting.
Occurs when your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress.

Trigger causes a sudden drop in your heart rate and blood pressure.
Leads to reduced blood flow to brain, resulting in brief loss of consciousness.

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8
Q

What is a prodrome?

A

an early symptom indicating the onset of a disease or illness

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9
Q

What is the prodrome of vasovagal syncope?

A 
Light-headed
Nausea
Hot, sweating
Tinnitus
Tunnel vision
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10
Q

What are the triggers for vasovagal syncope?

A 
Prolonged standing
Standing up quickly
Trauma
Venepuncture
Watching/experiencing medical procedures
Watching/experiencing medical procedures
Micturition
Coughing
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11
Q

What are the differences in features of Syncope vs Seizures leading up to an event

A

Syncope:

  • Upright posture
  • Pallor common
  • Gradual onset
  • Precipitants common

Seizure:

  • Any posture
  • Pallor uncommon
  • Sudden onset
  • Precipitants rare
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12
Q

What are the differences in features of Syncope vs Seizures during and after an event?

A

Syncope:

  • Injury rare
  • Incontinence rare
  • Rapid recovery

Seizure:

  • Injury quite common
  • Incontinence common
  • Slow recovery
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13
Q

What are Hypoxic seizures?

A

Occur when individuals are kept upright in a faint.

Can occur in aircraft, at the dentist, when well-meaning passerby help people to their feet.

Patient may have a succession of collapses

Seizure-like activity may occur

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14
Q

What are concussive seizures?

A

After any blow to the head

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15
Q

What are the 2 types of cardiac arrhythmias that may lead to seizure?

A

Structural cardiac abnormailities

Functional cardiac problems (Long QT syndromes)

Remember that seizures can cause cardiac arrhythmias

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16
Q

When should you consider functional cardiac problems in seizure?

A

Particularly when there is a family history of sudden death.
When there is a cardiac history
When collapse occurs with exercise

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17
Q

Explain Non-epileptic attacks

A
  • Commoner in women
  • Can be frequent
  • May look bizarre
  • Can be prolonged
  • May have a history of other medically -Unexplained symptoms
  • May have history of abuse
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18
Q

What may Non-epiletic attack appear like?

A

May superficially resemble a generalised tonic-clonic seizure

May resemble a “swoon”

May involve bizarre movements

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19
Q

What investigations must you carry out in a possible first seizure?

A

Blood sugar
ECG
Consideration of alcohol and drugs

CT head (see criteria)

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20
Q

What is some of the criteria for carrying out a CT scan on someone who has had a possible first seizure?

A

Prolongues seizure

Focal onset to siezure

Multiple seizures

(Check criteria)

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21
Q

What advice should you give to patients presenting with blackouts/
syncope/seizure?

A

Explain first seizure clinic and give information sheets

Ask about employment (may need to tell employer)

Potentially dangerous leisure activities?

Explain driving regulations

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22
Q

Would you give anti-epileptic drugs after 1st seizure?

A

Generally dont treat first seizure with anti-epileptic drugs

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23
Q

What are the driving regulations after these neurological events?

A

After a first seizure, a patient may drive a car after 6 months if their investigations are normal and they have had no further events.

They may drive an HGV or PSV after 5 years if investigations are normal, they have no further events and they are not on anti-epileptic medication

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24
Q

When should you diagnose epilepsy?

A

Normally diagnosed after a second unprovoked attack but sometimes on taking the history after a first seizure, if it is clear that they have undiagnosed epilepsy

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25
Q

What are the feautures suggestive of Primary Generalised Epilepsy?

A

History of:
Myoclonic jerks,
-especially first thing in the morning,

Absences or feeling strange with flickering lights

26
Q

What are the features of Focal Onset Epilepsy?

A

History of:
“Deja vu”,

Rising sensation from abdomen,

Episodes where look blank with lip-smacking, fiddling with clothes

27
Q

What is an epileptic seizure?

A

Intermittant stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds, is believed to result from abnormal neuronal discharges

28
Q

What is epilepsy?

A

Condition in which seizures recur, usually spontaneously

29
Q

What is the Epidemiology of Epilepsy?

A

Incidence:
.50-120 per 100,000 per year

Prevalence:
.5-8 per 1000
(Aberdeen 0.9%)
.22% of patients with learning disability have epilepsy
.3-5% of the population will experience at least 1 seizure in their lifetime

30
Q

How has epilepsy been classified?

A

Classified into groups using clinical data and EEG evidence.

Also a classification of epilepsy syndromes

31
Q

How are Generalised seizures classified?

A 
Tonic-clonic seizures
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Absence seizures
32
Q

What is a tonic-clonic seizure?

A

Tonic–clonic seizures = grand mal seizures

Type of generalized seizure that affects the entire brain.

Seizure type most commonly associated with epilepsy and seizures in general

33
Q

Describe the tonic phase of a tonic-clonic seizure

A

Quickly lose consciousness, and the skeletal muscles will suddenly tense, often causing the extremities to be pulled towards the body or rigidly pushed away from it, causing the patient to fall.
Usually the shortest part of the seizure, usually lasting only a few seconds.
May also express brief vocalizations like a loud moan or scream, due to air forcefully expelled from the lungs.

34
Q

Describe the clonic phase of a tonic-clonic seizure

A

Convulsions which may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities.
May roll and stretch as the seizure spreads.
The eyes typically roll back or close and the tongue often suffers bruising or lacerations sustained by strong jaw contractions.
The lips or extremities may turn slightly bluish (cyanosis) and incontinence is seen in some cases.

35
Q

What are myoclonic seizures?

A

Brief shock-like jerks of a muscle or group of muscles.
They occur in a variety of epilepsy syndromes that have different characteristics.
During a myoclonic seizure, the person is usually awake and able to think clearly.

36
Q

What is a clonic seizure?

A

“Clonus” means rapidly alternating contraction and relaxation of a muscle
(aka repeated jerking). The movements cannot be stopped by restraint. Clonic seizures are rare. Much more common are tonic-clonic seizures.

First aid usually isnt required and person may be able to carry on after seizure

37
Q

What is a tonic seizure?

A

The tone is greatly increased and the body, arms, or legs make sudden stiffening movements. Consciousness is usually preserved.
Tonic seizures most often occur during sleep and usually involve all or most of the brain, affecting both sides of the body.
If the person is standing when the seizure starts, he or she often will fall. These seizures usually last less than 20 seconds.

38
Q

What are atonic seizures?

A

Atonic seizures, are a type of seizure that consist of a brief lapse in muscle tone that are caused by temporary alterations in brain function.
The seizures are brief - usually less than 15 seconds.
The seizure itself causes no damage, but the loss of muscle control can result in indirect damage from falling.

39
Q

What is an absence seizure?

A

Absence seizures are lapses of awareness, sometimes with staring.
They begin and end abruptly, lasting only a few seconds.
More common in children.
Absence seizures can be so brief that they sometimes are not detected for months.

40
Q

How are Focal seizures classified?

A 
Acoording to aura
Motor features
Autonomic features
Degree of awareness
Degree of responsiveness
41
Q

Summarise Primary generalised epilepsy

A

No warning

42
Q

Summarise Focal/Partial epilepsy

A 
May get an "aura"
Any age (cause can be any focal brain abnormality)

Simple partial and complex partial seizures can become secondarily generalised

Focal abnormality on EEG
MRI may show cause

43
Q

How is epilepsy linked to learning difficulties?

A

Patients can have unclassifiable seizures which are unique to them

They can also have repetitive movements and apparently fairly stereotyped events which are behavioural but which can be difficult to diagnose

44
Q

What are the investigations for epilepsy?

A

EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation

MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age

Video-Telemetry if uncertainty about diagnosis

45
Q

What is the first line treatment for Primary generalised epilepsies?

A

Sodium Valproate
(best drug but also most teratogenic)

Lamotrigine
(not as good for myoclonic jerks)

Levetiracetam

46
Q

What is the treatment for partial and secondary generalised seizures?

A

Lamotrigine

Carbamazepine

47
Q

What is the treatment for absence seizures?

A

Ethosuximide

48
Q

What is Status Epilepticus?

A

Prolonged or recurrent tonic-cloinic seizures persisting for more than 30 mins with no recovery period between seizures.

Usually occurs in patients with no previous history of epilepsy
(stroke, tumour, alcohol)

49
Q

What is the first line treatment for Status Epilepticus?

A
  • Midazolam (10mg by buccal ir intra nasal, repeated after 10 mins if necessary)
  • Lorazepam (4mg bolus repeated once after 10 mins)
  • Diazepam (10-20mg iv or rectally, repeated after 15 mins)
50
Q

What is the second line treatment for generalised epilepsy?

A

Topiramate

Zonisamide

51
Q

What are some of the second line treatments for partial seizures?

A 
Sodium Valproate
Topiramate
Leviteracetam
Gabapectin
Pregabilin
Zonisamide
Lacosamide
Perampanel
Benzodiazepines
52
Q

What are some of the side effects of Sodium Valproate?

A

VALPROATE

V
A = Appetite  (-> weight gain)
L = Liver Failure
P = Pancreatitis
R = Reversible hair loss
O = Oedema
A = Ataxia
T = Tremor
E = Encephalopathy
53
Q

What are some of the side effects of Carbamazepine?

A
  • Ataxia
  • Drowsiness
  • Nystagmus
  • Blurred vision
  • Low serum sodium levels
  • Skin rash
54
Q

What are some of the side effects of Lamotrigine?

A

Skin rash

Difficulty sleeping

55
Q

What are some of the side effects of Levetiracetam?

A

Irritability

Depression

56
Q

What are some of the side effects of Topiramate?

A

Weight loss

Cognitive problems including word finding difficulties

Tingling hands and feet

57
Q

What is the side effect of Lacosamide?

A

DIzziness

58
Q

What is the side effect of Pregabilin?

A

Weight gain

59
Q

What are the side effects of Vigabatrin?

A

Behavioural problems and visual field defects

60
Q

What is the driving advice for epilepsy?

A

Patients can hold a Group 1 licence once they have been seizure free for a year or have only had seizures arising from sleep for a year.

They can only hold a HGV or PSV licence if they have been seizure free for 10 years and are not on anti-epileptic medication

61
Q

What is the second line treatment for Status Epilepticus?

A
  • Phenytoin (slow infusion of 15-18mg/kg at 50mg/min)
  • Phenobarbitone (10mg/kg at 100mg/min)
  • Valproate or levetiracetam (1g loading dose)
62
Q

What is the 3rd line treatment for Status Epilepticus?

A

Anaesthesia usually with propofol or thiopentone

N - C (35 decks)

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