Epilepsy Flashcards
what are common causes of loss of conciousness?
Vasovagal 20%
Reflex syncope 14%
Cardiogenic syncope 18%
Epilepsy 8%
Other (provoked seizure) 2%
Metabolic 4%
Unknown (including non-epileptic) 34%
what questions do you ask a patient who had passed out prior in their history?
What exactly were they doing at the time?
Prolonged standing, postural change, pain, vomiting, passing urine, coughing, exercising
What had they been doing in the previous 24 hours?
Sleep deprivation, excess alcohol, illicit drug use
Any warning symptoms?
Light-headed, nauseated, hot, sweating/cold sweat, loss of hearing, tinnitus, loss of vision
Rising feeling from abdomen, odd taste or smell, deja vu, sudden feeling of anxiety/panic
Palpitations/ cardiac symptoms
Also ask whether they have had previous episodes and how similar these were
Any awareness during event?
How they felt on recovery
First recollection
?bitten tongue ? incontinence
? prolonged confusion vs brief puzzlement
? Subsequent muscle pain, petechiae, shoulder dislocation
Detailed description of patient’s behaviour before, during and after the event
Duration
Level of responsiveness,
Colour
Motor phenomena
Breathing pattern
Vocalisation, salivation, blood in saliva
Incontinence,
Pulse
Rate of recovery and level of confusion
what warning symptoms may a patient have experienced prior to loss of conciousness?
Light-headed, nauseated, hot, sweating/cold sweat, loss of hearing, tinnitus, loss of vision
Rising feeling from abdomen, odd taste or smell, deja vu, sudden feeling of anxiety/panic
Palpitations/ cardiac symptoms
how may a patient feel on rec0very after loss of conciousness?
First recollection
?bitten tongue ? incontinence
? prolonged confusion vs brief puzzlement
? Subsequent muscle pain, petechiae, shoulder dislocation
what must be included in a detailed description of a patients behaviour before during and after loss of conciousness?
Duration
Level of responsiveness,
Colour
Motor phenomena
Breathing pattern
Vocalisation, salivation, blood in saliva
Incontinence,
Pulse
Rate of recovery and level of confusion
what are the three categories of syncope?
Reflex (neuro-cardiogenic)
Orthostatic - most common
Cardiogenic
what may cause reflex syncope?
Taking blood/medical situations
Cough, Micturation
what may cause orthostatic syncope?
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
what may cause cardiogenic syncope?
Arrhythmia, aortic stenosis
what is useful to always try and get in relation to a patient history of syncope?
Witness account
for example
Looked a bit pale
Suddenly went floppy
Looked pale
There may have been a few brief jerks
Brief LOC
Rapid recovery
If more prolonged was the patient propped up
which examinations do you do to assess syncope?
Heart sounds, pulse
Postural BPs
what would you look for in an ECG for syncope?
Look for heart block
QT ratio
when would a patient need a 24H ECG?
May need to see cardiology if recurrent (5 day recordings, reveal devices)
Consider Tilt table
give an example of a patient history with cardiogenic syncope?
History preceding events:
History of event itself:
Afterwards:
History preceding events
On exertion
History of event itself
Chest pain, palpitations, SOB
Afterwards
Chest pain, palpitations, SOB
Came round fairly quickly
Recovery may be longer
Clammy/sweaty
give an example of patient history with syncope?
History preceding events:
History of event itself:
Afterwards:
History preceding events
Stimulus- blood being taken, defecation
Context- only in bathroom, only when standing
History of event itself
Warning- felt lightheaded/clammy/vision blacking out
Afterwards
Very brief LOC
Came round as I hit the ground, Friend standing over them
Fully orientated quickly
Clammy/sweaty
Urinary incontinence
give an example of a patient history with non-epilecptic attack/pseudoseizure?
History preceding events:
History of event itself:
Afterwards:
History preceding events
Events may occur at times of stress or while at rest
Will often give lots of detail of others reaction and little of events themselves
History of event itself
May recall what people said during episode
May be prolonged episode, waxing and waining
May describe dissociation
Afterwards
Others reactions
what may a witness acount of a pseudoseizure include?
Description
May recognise stress as a trigger (even if patient doesn’t)
May report signs of patient retaining awareness
Tracking eye movements, still some verbalisation during episodes
Movements not typical of seizures
Pelvic thrusting
Asynchronous movements, tremor
Episodes waxing and waining
Ideally we try and capture a typical episode on EEG
-Important to make diagnosis to avoid iatrogenic harm
why may a seizure be provoked?
(Febrile convulsions in childhood)
Alcohol withdrawal
Drug withdrawal
Within few days after a head injury
Within 24hrs of stroke
Within 24hrs of neurosurgery
With severe electrolyte disturbance
Eclampsia
what is epilepsy?
the tendency to recurrent seizures
we use the term Epilepsy if patients have more than one unprovoked seizure
how do seizures occur?
Our neurones have background electrical activity. If this is disrupted it can lead to a seizure
what causes synchronous discharges in cortical neurons?
too much excitation
damaged neurons
too little inhibition
what causes too little inhibition?
GABA receptors
what causes damage to neurons?
stroke, tumour, trauma, developmental causes
what causes too much excitation?
glutamate receptors
ion channels (Na/Ca2+)
excitatory amino acids
what factors increase seizure risk?
Missed medications (most common)
Sleep disturbance, fatigue
Hormonal changes, menstrual cycle
Drug/alcohol use, drug interactions
Stress/Anxiety
Photosensitivity in a small group of patients
Other rarer reflex epilepsies (visual patterns, music)
what are different classes of generalised seizures?
Absence seizures
Generalised tonic-clonic seizures
Myoclonic seizures
Juvenile myoclonic epilepsy
Atonic seizures
