Epilepsy Flashcards
Epilepsy is defined as
a ‘tendency to recurrence of seizures’
It is a symptom, not a disease.
A person should not be labelled ‘epileptic’ until at least two attacks have occurred.
Use monotherapy for prescribing if possible.
First-line medication is valproate, or carbamazepine.
For females of reproductive age, valproate is out and lamotrigine is in.
Types of epilepsy
Epileptic seizures are classified in general terms as:
- generalised
- partial
Partial seizures are about twice as common as generalised seizures
- usually due to acquired pathology.
Generalised seizures
Motor—convulsive:
- tonic–clonic (previously called grand mal)
- clonic
- myoclonic
- secondary generalised
Motor—non-convulsive:
- tonic (drop attacks)
- atonic (drop attacks)
Non-motor (absence):
- typical absence—childhood (petit mal) and juvenile
- atypical absence
- eyelid myoclonia
Focal (partial) seizures
Simple partial (consciousness retained):
- with motor signs (Jacksonian)
- with somatosensory symptoms
- with psychic symptoms
Complex partial (consciousness impaired)
Emergency management: using doctor’s bag supplies (adults)
All serious medical conditions, don’t forget:
- secure IV line
- oxygen (where indicated)
Acute pulmonary oedema (left ventricular failure)
- frusemide 40–80 mg IV (or twice usual dose)
- glyceryl trinitrate 1 dose (spray) or tablet
- consider (esp. if chest pain)—morphine 2.5–5 mg IV
- CPAP for unresponsive cases (usu. ambulance)
Acute anaphylaxis
- adrenaline 0.3–0.5 mg (1:1000) IM, repeat every 5 mins as nec.
If no rapid improvement:
- salbutamol inhalation
- IV fluids
- adrenaline infusion
- hydrocortisone/glucagon/antihistamines
Angio-oedema + acute urticaria
- promethazine 25 mg IM or prednisolone 25–50 mg (o) as single dose
Asthma (severe)
- salbutamol 6 (<6 yrs) – 12 (adults) puffs by spacer (4 × 4 × 4 rule)
- hydrocortisone 200–250 mg IV or IM
If severe (hospital):
- adrenaline 0.3–0.5 mg 1:1000 IM or SC or infusion in N saline
Croup (severe)
- dexamethasone 0.15 mg/kg IM or prednisolone Img/kg(0)Page 225
Epilepsy (seizure)
- midazolam 0.2 mg/kg IM or IV or bucally or diazepam 5–20 mg IV (rate ≤2 mg/min)
Opiate respiratory depression
- naloxone HCl 0.2–0.4 mg IV + 0.4 mg IM
Myocardial infarction
- aspirin 300 mg soluble tab
- glyceryl trinitrate spray or tabs (max. 3)
- morphine sulphate 2.5–5 mg IV (if pain)
Hypoglycaemia
- glucagon 1 mg/mL SC, IM or IV, then sweet drink or 20–30 mL 50% glucose IV
Migraine (severe)
- prochlorperazine 12.5 mg IV or
- metoclopramide 10 mg IV or
- haloperidol 5 mg IM or IV
Cluster headache
- 100% oxygen 6 L/min for 15 mins
- metoclopramide 10 mg IV
Movement disorders (from antipsychotic medication)
- benztropine 1–2 mg IV or IM
Meningococcaemia
•benzylpenicillin 60 mg/kg IV or ceftriaxone ( 90)
Uretic colic
- morphine 10–15 mg IM or IV ± metoclopramide
- indomethacin suppository
Vertigo (acute)
- prochlorperazine 12.5–25 mg IM or promethazine 25 mg IM
Vomiting
- prochlorperazine 12.5 mg IM or IV or metoclopramide 10 mg
Management
Do not usually treat on one fit (chance of a further seizure is about 70%),
- usually after second seizure when diagnosis confirmed
OR
- when 2+ within 6–12 mths
Profound psychosocial support
Education, counselling, advocacy
Appropriate referral
Initial management of epileptic seizure
Medication
Sodium valproate (first choice)
Adults: 500 mg (o)/d for 1 wk, then bd for 1 wk, ↑ every 2–4 wks to achieve control (up to 2–3 g/d)
- Some prefer carbamazepine or lamotrigine in young women
- because of risk of teratogenicity with valproate which, however, is less sedating.
Carbamazepine (2nd choice)
Other choices: usually added on to achieve optimal control—check interactions
- phenytoin
- lamotrigine
- topiramate
- levetiracetam
Continue treatment until fit-free for at least 2 yrs.
Avoid use of prochlorperazine and benzodiazepines. Monitor with annual LFTs and FBE.
Simple partial seizures
there is no loss of consciousness.
These include focal seizures
- which may proceed to a generalised tonic-clonic seizure
- or to motor seizures—Jacksonian epilepsy.
Jacksonian (motor seizure)
- Typically, jerking movements
- begin at the angle of the mouth
- or in the thumb and index finger
- and ‘march’ to involve the rest of the body,
e. g. thumb → hand → limb → face ± leg on one side and then on to the contralateral side.
* A tonic-clonic or complex partial seizure may follow.
Medication: As for complex partial seizures.
Complex partial seizures
It is the commonest type of focal epilepsy
- the attacks vary in time from momentary to several minutes (av. 1–3 mins).
Possible manifestations of complex partial seizures
Commonest: slight disturbance of perception and consciousness
Hallucinations—visual, taste, smell, sounds
Absence attacks or vertigo
Affective feelings—fear, anxiety, anger
Dyscognitive effects, e.g. deja vu (familiarity), jamais vu (unreality)
Objective signs:
- lip-smacking
- swallowing/chewing/sucking
- unresponsive to commands or questions
- pacing around a room
Unreal or detached feelings and post-ictal confusion are common in complex partial seizures.
- There can be permanent short-term memory loss.
Diagnosis of complex partial seizures
EEG-diagnostic in 50–60% of cases;
- a repeat EEG will increase diagnostic rate
EEG/video telemetry
- helpful with frequent attacks
CT or MRI scan—
- to exclude tumour when diagnosis confirmed
Medication of complex partial seizures
Carbamazepine (1st choice) 200 mg/d ↑ gradually by 100 mg/wk to control or
Sodium valproate (2nd choice)
Other choices: phenytoin, lamotrigine, gabapentin, vigabatrin, tiagabine
Status epilepticus
Status is >1 seizure
- without regaining consciousness
- or fitting >20 mins.
Focal status
A high index of suspicion is needed to diagnose
Oral medication usually adequate
Avoid overtreatment
