Epilepsy Flashcards
What is epilepsy?
- Seizure = transient occurrence of signs and symptoms due to abnormally excessive or synchronous neuronal activity within the brain
- Epilepsy = repeated seizures
How are seizures classified?
- Generalised = both hemispheres
- motor (movement) – stiffening (tonic) and jerking (clonic)
- non motor – a.k.a ABSENCE seizures – there are changes in sensations, emotions, thinking or experiences known as aura
- Focal = one hemispheres
- aware (simple)
- unaware (complex)
- Focal to bilateral = one hemisphere then progresses to both hemispheres
What is the prevalence of epilepsy in the UK?
456,000
What proportion of people will have 1 seizure in their lifetime?
1 in 20
What % of the epilepsy population have learning disabilities?
25%
What % of the treatment resistant epilepsy population have learning disabilities?
60%
What is the geographical distribution of epilepsy?
Higher prevalence in HICs
What is the aetiology of seizures?
VITAMINS
Vascular – stroke, hypertension
Infections – meningitis, encephalitis
Toxins – alcohol overdose, medications (antidepressants, antipsychotics)
AV malformations + space occupying lesions + Autoimmune (e.g., vasculitis)
Metabolic – hypoglycaemia, hypo/hypernatremia, hypocalcaemia + Multiple Sclerosis
Idiopathic
Neoplasms
Stress – trigger and predisposing factor
What are the clinical features of a tonic clonic (i.e., grand mal) seizure?
Limb contraction
Limb extension
Arching of back
Ictal cry due to chest contraction
Usually lasts 2-3 minutes
What are the clinical features of a tonic seizure?
Sustained contraction
Cyanosis
What are the clinical features of a clonic seizure?
Jerking movements
What are the clinical features of a myoclonic seizure?
Feature muscle spasms either in select muscle groups or across the body
What are the clinical features of absence seizures (i.e., petit mal)?
May have little or no motor involvement
Usually lasts 10 seconds
What are the clinical features of a atonic seizure?
Bilateral loss of muscle activity > 1s
What is status epilepticus?
Either:
- Seizure lasts more than 5 mins
- 2 or more seizures without return to consciousness
- 3 or more tonic-clonic seizures within a 1-hour timeframe
MEDICAL EMERGENCY
Airway management
Medications – benzodiazepine, phenytoin and phenobarbital
What is the post-ictal phase? What are its features?
Follows seizures
Lasts mins to hours
Confusion
Tiredness
Headache
Speech difficulty
Psychosis (in 10%)
Amnesia
What assessments and investigations can you do for someone that presents with a seizure?
- History – seizure & post-ictal phase, drug/alcohol use
- Physical exam – tongue biting, injuries: shoulder dislocation
- Blood tests – blood sugars, U&Es (to check electrolyte levels)
- Imaging – CT, MRI (recommended in the 1st instance of a seizure to exclude structural causes)
- Lumbar puncture
- EEG – (when an organic cause has not been identified, Epilepsy syndrome investigation
- Prolactin
How would you manage someone presenting with a seizure?
Start the stopwatch/timer (if it hasn’t already been started)
A-E assessment
Secure environment by removing any hazardous materials
Airway management by placing in recovery position and using airway adjuncts if airway is compromised
Medications
1. Benzodiazepines (e.g., lorazepam, diazepam) – a 2nd dose of benzodiazepine may be given after 10 minutes. If this doesn’t work proceed to step 2.
2. Barbituates, propofol
3. Phenytoin – low dose and maintenance dose
Give glucose if needed
Refer for follow up
- Specialist clinic
- Antiepileptic drugs – valproate, lamotrigine and levetiracetam
After the initial seizure Mx, your patient has not responded and is still convulsing. What should you do in the initial 5-10 minutes if the patient has IV access?
Lorazepam 4mg IV bolus
Monitor and give 2nd dose after 10 minutes if seizures continue
After the initial seizure Mx, your patient has not responded and is still convulsing. What should you do in the initial 5-10 minutes if the patient has IV access, but there is a lorazepam shortage?
Diazepam 10mg slow IV injection (max rate = 1mL(5mg) per minute)
Monitor and give 2nd dose after 5 minutes if seizures continue
After the initial seizure Mx, your patient has not responded and is still convulsing. What should you do in the initial 5-10 minutes if the patient has no IV access?
Diazepam 10mg PR
OR
Midazolam 10mg buccal
OR
Midazolam 10mg IM (ITU only)
Monitor and give 2nd dose after 10 minutes if seizures continue
After the initial seizure Mx, your patient has not responded and is still convulsing. What should you do in the at 10-30 minutes?
Established status epilepticus - risk of long-term brain damage
Call MET team (2222) - start emergency IV anti-epileptic drug (AED) therapy ASAP
Tx options:
- levetiracetam 60mg/kg IV infusion (max 4500mg)
- sodium valproate 40mg/kg IV infusion (max 3000mg)
- phenytoin 20mg/kg IV infusion (max 2000mg)
Inform the anaesthetist/request airway support if patient is still in status epilepticus after 50% of infusion has been given
If the patient that you are treating as status epilepticus’ seizure resolves at 30 minute what should you do?
Reinstate existing anti-epileptic meds (via PO/IV/NG route)
- ward/on call pharmacist or on-call neurologist can advise if alternative formulations or route of administration is required
Monitor neurological observations and GCS every 30 minutes and if patient does not regain consciousness within 1-2 hours call for senior help
- continue neuro obs 4-hourly for the next 12 hours
Establish aetiology, identify and treat med complications
If the patient that you are treating as status epilepticus’ seizure continue at 30 minute onwards what should you do?
Transfer to HDU/ITU
