Blackouts, Seizures and Epilepsy Flashcards
Define syncope
Transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
Categories of syncope
Reflex
Orthostatic
Cardiac
Types of reflex syncope
Vasovagal
Situational
Carotid sinus
Types of orthostatic syncope
Primary autonomic failure
Secondary autonomic failure
Drug-induced
Volume depletion
Types of cardiac syncope
Arrhythmias
Structural
PE
What is vasovagal syncope?
Triggered by emotion, pain, or stress
“Fainting”
Causes of situational syncope
Cough
Micturition
GI
Causes of primary autonomic failure
Parkinson’s disease
Lewy body dementia
Causes of secondary autonomic failure
Diabetic neuropathy
Amyloidosis
Uraemia
Common syncope-inducing drugs
Diuretics
Alcohol
Vasodilators
Antipsychotics
Antidepressants
Investigations for syncope
CV exam
Postural blood pressure readings
ECG
Carotid sinus massage
Tilt table test
24hr ECG
How to differentiate between seizures and syncope
Thorough history covering:
Risk factors
Triggers
Before episode
During episode
After episode
Risk factors for syncope
Heart disease (arrhythmias)
Peripheral neuropathy
Drugs that cause postural hypotension
Risk factors for seizures
FHx
Previous history of epilepsy
Head injury
CNS infection
Triggers for syncope
Pain
Heat
Exertion
Prolonged standing
Emotion
Triggers for seizures
Alcohol
Sleep deprivation
Bright lights
Infections
Syncope: before episode
Dizziness
Light-headedness
Nausea
Tunnelled vision
Seizures: before episode
Aura
Epigastric rising
Deja vu
Visual/smell disturbances
Syncope: during episode
Sudden loss of tone
May have tongue biting and incontinence
Brief duration
Seizures: during episode
Tonic-clonic jerking movements
May have tongue biting and incontinence
May be brief or prolonged
Syncope: after episode
Complete and rapid recovery
Seizures: after episode
Post-ictal confusion and drowsiness
May have Todd’s facial palsy
Features of seizures
Generalised seizures usually sudden onset
Tongue biting and incontinence may occur
<5 minutes
Post-ictal confusion
What are Stokes-Adams attacks?
Arrhythmogenic syncope
Abrupt onset
Without waring
May result in significant injury
Myoclonic jerks may occur
Features of pseudoseizures
Often prolonged episodes (rarely <1 minute, often >30 minutes)
Usually in front of a witness
Fluctuating motor activity and seizure-like convulsions
Tongue biting rare
Classification of focal (partial) seizures
Part of the brain that they involve (e.g. temporal versus frontal lobe seizures)
Whether consciousness is impaired (simple versus complex)
Types of generalised seizure
Tonic
Tonic-clonic
Atonic
Myoclonic
Absence
Basic seizure classification
3 features
Where seizures begin in the brain
Level of awareness during a seizure
Other features of seizures
Describe generalised tonic-clonic seizures
LOC andtonic(muscle tensing) andclonic(muscle jerking) episodes
Typically tonic phase precedes clonic phase
May be tongue biting, incontinence, groaning and irregular breathing
Prolongedpost-ictal periodwhere person is confused, drowsy and feels irritable or depressed
Management of generalised tonic-clonic seizures
generaLiSed
Sodium valproate
2nd line: Lamotrigine or carbamazepine
Describe focal seizures
Start in temporal lobes
Affect speech, hearing, memory and emotions
Hallucinations
Memory flashbacks
Déjà vu
Doing strange things on autopilot
Management of focal seizures
foCaL
Carbamazepine or lamotrigine
2nd line: sodium valproate or levetiracetam
Describe absence seizures
Typically occur in children
Patient becomes blank, stares into space and then abruptly returns to normal
Unaware of their surroundings and won’t respond
Typically 10-20 secs
Management of absence seizures
Sodium valproate or ethosuximide
Describe atonic seizures (“drop attacks”)
Brief lapses in muscle tone
Usually <3 minutes
Typically begin in childhood
What might atonic seizures/drop attacks be indicative of?
Lennox-Gustaut syndrome
Management of atonic seizures/drop attacks
Sodium valproate
2nd line: lamotrigine
Describe myoclonic seizures
Sudden brief muscle contractions, like a sudden “jump”
Usually remain awake during episode
Occur in various forms of epilepsy but typically in children as part ofjuvenile myoclonic epilepsy
Management of myoclonic seizures
Sodium valproate
Other options:
Lamotrigine,levetiracetamortopiramate
Investigations in seizures
EEG
MRI to diagnose structural problems
ECG to exclude cardiac problems
Features of temporal lobe focal seizures
HEAD
Hallucinations
Epigastric rising/Emotional
Automatisms (lip smacking/grabbing/plucking)
Deja vu/Dysphasia post-ictal
Features of frontal lobe seizures
MOTOR
Head/leg movements
Posturing
Post-ictal weakness
Jacksonian march
SENSORY
Paraesthesia
Features of occipital lobe seizures
VISUAL
Floaters/flashes
Management of seizures
Start anti-epileptics following second epileptic seizure
Generalised: sodium valproate
Focal: carbamazepine
Acute management of seizures
If not terminated after 5-10 minutes may be appropriate to administer medication
Benzodiazepines e.g. diazepam
Driving & seizures
Cannot drive for 6 months following seizure
Epileptic patients must be seizure free for 12 months before being able to drive
Trying to conceive
Valproate particularly teratogenic
Define status epilepticus
Single seizure lasting>5 minutesor>3 seizures in 30 minute period without return to normal in between
Management of status epilepticus
in hospital
ABCDE
IVlorazepam4mg, repeated after 10 minutes if the seizure continues (diazepam pre-hospital)
If seizures persist: IVphenobarbitalorphenytoin
If no response, induce general anaesthesia
Management of status epilepticus
in community
Buccal midazolam
Rectal diazepam
Investigations in status epilepticus
Check o2 sats and blood sugar (common and rapidly reversible cause)
ABG
FBC, U&E, LFT, CRP, calcium and magnesium, clotting
Serum and urine save for toxicology
Anti-epileptic drug levels should be sent as appropriate
What is important before administering glucose in patients with a history of alcohol abuse?
IV pabrinex prior to the administration of glucose to avoid precipitation of Wernicke’s encephalopathy or Korsakoff’s syndrome
Chance of developing MS after single episode of optic neuritis?
50%
Optic neuritis features
CRAP
Central scotoma
RAPD
Acuity (unilateral decrease in HR/D)
Pain worse on movement
