Core conditions 3 Flashcards
Glycaemic index (GI)
The 2 hour blood glucose response to 50grams of food. A low glycaemic index diet is beneficial to diabetes.
Exercise recommendation
Recommendation of 30mins on at least 5 days of the week for moderate intensity. For example: walking groups or swimming.
T2D: BP target and review
Blood pressure target in diabetes: 140/90
Patients with T2D get an annual review
The 2 investigations to check for evidence of kidney disease
A blood test for u+es and an early morning urine sample to measure thealbumin:creatinineratio (ACR). Urine dipsticks are less accurate for proteinuria
Focal seizures
- These start in a specific area, on one side of the brain
- thelevel of awarenesscan vary in focal seizures. The termsfocal awarefocal impaired awarenessand awareness unknown are used to further describe focal seizures
- further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura
Generalised seizures
- these engage or involve networks on both sides of the brain at the onset
- consciousness lost immediately. The level of awareness in the above classification is therefore not needed, as all patients lose consciousness
- generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence)
- specific types include: tonic-clonic (grand mal), tonic, clonic, typical absence (petit mal), atonic
Tonic clonic seizure
Tonic phase where patient becomes rigid followed by clonic phase where the limbs shake rhythmically and symmetrically. Have a post ictal phase with reduced GCS and muscle tone, risk of aspiration. Tonic phase is preceded by shouting as air is expelled from the lungs
Absence seizures and focal onset to tonic clonic
- Absence: causes a brief (normally <10s) period of loss of awareness. May look upwards with fluttering eyelids. Patients unaware of what happened
- Tonic-clonic seizures that have “warning” symptoms tend to represent a focal-onset seizure that progresses into a generalised tonic-clonic seizure i.e. smelling burnt toast
Status epilepticus is defined as
- a single seizure lasting >5 minutes, or
- > = 2 seizures within a 5-minute period without the person returning to normal between them
Management of status epilepticus <10min
- ABC= airway adjunct, oxygen, check blood glucose
- First-line drugs are benzodiazepines= in theprehospital setting PR diazepam or buccal midazolammay be given. in hospitalIV lorazepamis generally used. This may berepeated onceafter 5-10minutes
Management of status epilepticus >10 minutes
- If ongoing (or ‘established’) status it is appropriate to start a second-line agent such aslevetiracetam, phenytoin or sodium valproate
- If no response (‘refractory status’) within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia or phenobarbital.
Medication for generalised tonic-clonic seizures
- males:sodium valproate
- females:lamotrigine or levetiracetam
- girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
Treatment for epilepsy
- Focal seizures: Lamotrigine or levetiracetam
- Absence seizures (Petit mal): Ethosuximide
- Myoclonic seizures: in males its sodium valproate and in females its Levetiracetman
- Tonic or atonic seizures: in males its sodium valproate and in females its Lamotrigine
Provoked seizures
- physical trauma (immediately after a head injury)
- acute vascular injury (at onset of stroke for example)
- metabolic disturbance (hypoglycaemia or hyponatraemia for example)
- stimulant drugs (e.g. amphetamines or MDMA)
- withdrawal from sedative drugs (e.g. alcohol or benzodiazepines).
Epilepsy
A disorder of the brain characterised by an enduring predisposition to epileptic seizures. In children its usually genetic or metabolic. In adults its triggered by a physical structural change i.e. tumour, stroke, traumatic brain injury and inflammatory brain condition i.e. MS
Diagnosis of epilepsy
The official diagnosis of epilepsy requires 2+ unprovoked seizures within 5 years, the seizures must be >24hours apart. If there are clinical features which suggest an enduring predisposition to seizures, then epilepsy is sometimes diagnosed after just 1 seizure. These cases may involve a structural cause or EEG changes.
Seizures related to brain lobes
- Frontal: motor (tonic, clonic, posturing), rapid onset, motor/vocal agitation, emotional lability
- Parietal: Somatosensory paraesthesia/illusion, dysphagia, visual (objects appear larger/smaller)
- Temporal: Automatisms (lip smacking, chewing), Autonomic features (epigastric sensation, tachycardia, palpitations), auditory hallucinations, Deja vu, feeling of dread/fear, abnormal tastes or smells
- Occipital lobe: visual hallucinations, eye movement
Seizures: frontal onset to generalised tonic clonic
More common in adults. Persistent area of damage acts as focus of abnormal electrical activity which spreads to the rest of the cortex
Epilepsy investigations
- Bloods: FBC, U&E, LFT
- ABG: raised lactate supports diagnosis
- EEG: can tell if attack is caused by electrical disturbance
- ECG
- MRI head: use if focal onset, onset in adulthood or before age 2, epilepsy refractory to anti-epileptics. Looks for structural cause
Seizure: what increases risk of re-occurrence
- Persistently abnormal neurological examination
- Focal area of change on the MRI (e.g. previous stroke) acting as a focus to generate seizures. These would be termed “remote symptomatic seizures”.
- Epileptiform abnormalities on EEG
- A seizure that occurred during sleep
- Two unprovoked seizure >48 hours apart
