Epilepsy Flashcards
Suggest 4 fts in a history that point towards a diagnosis of a seizure as opposed to syncope/dissociative attack?
- LOC/amnesia > 5 mins
- aura: prodromal focal features or none
- motor fts e.g. head turning unusual posturing, prolonged, prominent, rigid, rhythmic
- lateral tongue biting, incontinence, injury
- confused behaviour, post event headache/myalgia
- unprovoked
Sheldon’s Questionnaire, scores for liklihood of seizure > syncope, give 3 of the features on this questionnaire
- lateral tongue biting
- deja or jamais vu before LOC
- emotional stress associated with LoC
- confusion following LoC
- head turning during attack
- unresponsive/unusual posturing/amnesia
How to initially manage syncope? Initial after transient loss of consciousness, what is the 1st ix to do?
-then for simple faint
-for pathological syncope (what are 4 red flags?)
Next step if present, is refer to___ ?
- ECG!! (and document findings)
- dx: uncomplicated vasovagal syncope, no red flags then can just explain and reassure, appropriate safety advice and discharge
- dx: path. syncope - refer to CARDIO WITHIN 24hrs
- red flags: any ECG abnormality, HF, murmur, new unexplained SOB, transient LOC on exertion, or unprovoked/at rest or Fam Hx of sudden cardiac death <40yrs, >65yrs t LOC with no prodrome
Dissociative vs Epileptic Seizure differentiation
-what fts favour dissociative seizures (aka non-epileptic functional seizures)
- > 5mins duration of individual events
- fluctuating course (wax and wanes)
- asynchronous rhythmic movements
- pelvic thrusting
- side to side head/body movements
- closed eyes
- ictal crying
- recall of items during event
If new onset suspected seizure/epilepsy what ix and management will be needed?
- tests? imaging?
- advice on what?
- referral to who?
- ECG and exclude acute metabolic cause
- CT if focal fts, prolonged or recurrent
- Provide suspected seizure info (DVLA, safety, lifestyle) - bathing/heights/machinery/occupational/parenting/swimming
- consider home video if recurrent episodes
- say “by law no driving until you’ve seen the specialist”
- first fit neurology referral (will organise MRI/EEG if needed
If known epileptic presents to you with change in attacks or more frequent attacks, what should you do in terms of history ?
- ensure dx is right (go through same process as initial seizure presentation, document hx that supports type of seizure/epilpsy)
- worst and best seizure frequency to gage seriousness
- document co-morbidities
- current medication and what’s been tried before/recent changes to medication
- ask re: compliance
If known epileptic presents to you with change in attacks or more frequent attacks, what should you do in terms of assessment/management?
- consider triggers e.g. stress, infection, ETOH
- FBC, biochem (rule out metabolic causes)
- AED LEVELS (anti-epileptic drug levels)
- seek advice from neurologist/epilepsy clinic that manages that pt
- advise home video if diagnostic doubt of epilepsy
Basic First Aid Advice for a tonic clonic seizure: A C T I O N
+(call for help and consider rescue meds)
Assess - ensure safe, minimise injury risk
Cushion
Time
Identity (bracelet/ID card)
Over (recovery position, consider O2, gueddel airway..)
Never: restrain, put anything in mouth
What is status epilepticus?
NB: there are multiple types of SE for all seizures, but one is an emergency, which is?
-what are the T1 T2 time points
Prolonged seizure
Unlikely to self-terminate (T1) = 5mins
Risk of damage due to seizure itself and metabolic consequences (T2) = 30mins
-convulsive (tonic-clonic) SE is a MEDICAL EMERGENCY
What do these refer to in SE?
(T1) = 5mins
(T2) = 30mins
- > 5mins is defined as SE as is v unlikely to self-terminate
- > 30mins is timepoint of risk of damage due to seizure itself and metabolic consequences
NB: sooner rx is started, the more likely it will work so don’t delay!
Why does T2 ->30mins is timepoint of risk of damage due to seizure itself and metabolic consequences happen?
- phase 1 of seizures what happens?
- phase 2?
- Phase 1: BP, O2, glucose utilisation and blood flow to brain increases. More lactate generated from muscles activity
- Phase 2: ~30mins, due to the electrical storm, the brain and muscles cannot keep up with the demands so –> BP normal/low, glucose falls, lactate rises more and pH drops
- can lead to respiratory compromise and hypothermia
What is the convulsive SE overview for management?
- resuscitation and general medical support (ABCDE)
- give 250mg thiamine and 30% glucose (as alcohol withdrawal is a common cause, and if not doesn’t do much harm)
- confirm the dx (video if doubt, is it dissociative?)
- stop the seizures
- identify/treat the cause
- establish maintenance anti-epileptic drugs.
How to stop the seizures of SE?
-Premonitory/Initial SE
NB: sooner given the better
Initial
- benzodiazepines e.g. 10mg buccal midazolam/rectal diazepam or if have IV access give 4mg IV lorazepam
- maximum x2 doses
- How to stop the seizures of SE?
- Established SE (SE that hasn’t responded to benzos therefore aka benzo refractory SE)
- who should be notified at this stage?
Established: -Valproate 40mg/KG or -Levetiracetam 60mg/KG (phenytoin 20gm/kg no longer 1st line) (call anaesthetist to notify pt - relates to next step if rx unsuccessful)
-How to stop the seizures of SE?
if refractory to benzos and valproate/levetiracetam?
-anaesthesia/ITU management
General principle of which drugs are best for following:
- new onset focal epilepsies:
- most effective for generalised seizures:
- broad spectrum for either above:
- new onset focal epilepsies: lamotrigine
- most effective for generalised seizures: valproate
- broad spectrum for either above: levetiracetam
Drug resistant epilepsy (can’t achieve complete seizure control) meds still help so should be continued, but what else may be poss to help?
- surgery for localisation related with identifiable lesion e.g. hippocampal sclerosis, cavernoma, tumour.. can be curative but rare
- electrical stimulation therapies (VNS-vagal nerve stimulation, DBS)
- newer agents in clinical trials
Long-term management of epilepsy: (holistic ideas, suggest 3 aspects)
- shared care (primary, 2nry and 3ry care) that is flexible and responsive to pt needs
- decisions about initiation/change and discontinuation of AEDs made by specialist
- pt education, encourage autonomy
- access to info (lifestyle, occupation, meds, preg, contraception)
- access to specialist advice
Drug resistant epilepsy (can’t achieve complete seizure control) meds still help so should be continued, but what else may be poss to help?
- surgery for localisation related with identifiable lesion e.g. hippocampal sclerosis, cavernoma, tumour.. can be curative but rare
- electrical stimulation therapies (VNS-vagal nerve stimulation, DBS)
- newer agents in clinical trials
As antiepileptic drugs (AEDs) as a group dampen down excessive neuronal activity, suggest 3 common SEs?
-what v dangerous allergic reaction can occur with a few AEDs in a small%?
- CNS: sedation, unsteadiness, diplopia
- Weight (gain or loss due to appetite sensors/gut)
- behavioural/psychiatric SEs
- GIT nausea/vomiting
-rare: allergic rash can –> steven johnson’s syndrome (!)
As antiepileptic drugs (AEDs) as a group dampen down excessive neuronal activity, suggest 3 common SEs?
-what v dangerous allergic reaction can occur with a few AEDs in a small%?
- CNS: sedation, unsteadiness, diplopia
- Weight (gain or loss due to appetite sensors/gut)
- behavioural/psychiatric SEs
- GIT nausea/vomiting
-rare: allergic rash upon initiation can –> steven johnson’s syndrome (!)
Which AED is commonly associated with agranularcytosis so warn pts about a severe sore throat?
Carbamazepine
What guides choice of AED for treatment?
-pt factors
- seizure type, frequency, severity
- syndromic classification (focal, generalised, other)
- women of child bearing age
- co-morbidities e.g. overweight, anxiety disorder
What guides choice of AED for treatment?
-drug factors
- ease of use (interactions, formulation, speed) e.g. can they swallow tablets, can they take BD pill burden
- effectiveness, tolerability and safety (trial and error)
- cost effectiveness / availability
