Epilepsy Flashcards
acute epilepsy - investigations
B - oxygen
C - BP + ECG
D - glucose, calcium, U+Es (derangements)
E - neuro exam (do urgent CT brain if abnormal)
epilepsy counselling - what can increase seizure likelihood - what to avoid + what situations to be careful in
illness + vomiting drug sleep deprivation new medications/rec drugs alcohol + next day not eaten
lamotrigine SEs
sedation/insomnia
dizziness
nausea
allergic skin rash
multisystem hypersensitivity - fever
how should epilepsy be managed when planning pregnancy? (what to do before pregnant)
start lowest dose lamotrigine
prophylactic folic acid 5mg until trim 1 +
when + how should epilepsy drugs be started? what to do if they fail?
1 seizure - not recommended
1 every 2 years - may not need if not driving/machinery
2 seizures - consider
build up dose over 2-3mo
if all drugs fail - dual therapy
dual therapy fails - resection of epileptogenic focus or vagal nerve stimulation
what are 1st and 2nd line drugs given in epilepsy?
1 - sodium valproate or lamotrigine (better tolerated/less teratogenic)
2 - carbamazepine or topiramate
lamotrigine - SEs
rash/flu - stevens-johnson
fever - hypersensitivity
blurred/double vision
tremor
nausea + dizziness
valproate SEs
hair loss
weight gain
teratogenicity
hepatotoxicity - monitor LFTs in 1st 6mo
cough, sore throat, bruising
extreme tiredness, abdo pain, jaundice
breastfeeding + epilepsy meds
use lamotrigine only
status epilepticus in pregnancy
eclampsia likely
check urine + BP
may need ASAP delivery
status epilepticus - management overview
call ICU
ABCDE
rule out hypoxia + hypoglycaemia before ?other causes
status epilepticus - investigations
A+ B - ABG, sats
C - cardiac monitor, FBC
D - glucose, U&E, calcium
E - consider LP, CT
status epilepticus - management
1 - recovery position
A - open + insert airway (intubate if necessary)
B - 100% oxygen + suction
C - IV access + take blood
D - IV lorazepam bolus, repeat in 10 min if no response; or buccal midazolam
E - fluids for hypoTN
what to do if lorazepam bolus doesn’t work in status epilepticus?
IV infusion of valproate/phenytoin
if phenytoin - monitor ECG/BP (can cause low BP); can cause soft tissue necrosis if it leaks from a vein
last resort - ICU, GA, continuous EEG
GA if no response in 30min
what does a pseudoseizure look like?
no response to diazepam infusion
pelvic thrusts
resisting your attempts to open lids/do passive movements
flailing limbs
what to do when status epilepticus controlled
LP + MRI if indicated
start oral meds
identify cause:
drugs - alcohol/drugs/inadequate meds
illness - CNS lesion/infection
other - low glucose, pregnant
seizure vs syncope
syncope:
rapid recovery + short post-ictal period
less violent jerking of limbs
incontinence/tongue-biting v rare
seizure - much longer post-ictal period - oft 15m drowsy
more violent jerking of limbs
cardiac arrhythmia - may have cardiac symptoms before
generalised seizures - features + types?
always immediate LOC
motor type - eg tonic-clonic
non-motor type - eg absence
tonic-clonic (grand mal) tonic or clonic typical absence (petit mal) myoclonic - brief, rapid muscle jerks atonic
infantile spasms (west’s syndrome)
brief spasms in first few months of life
1) flexion of head, trunk, limbs → extension of arms (Salaam attack) - lasts 1-2s + repeats up to 50x
2) progressive mental handicap - poor prog
3) EEG - hypsarrhythmia
usually 2° to serious neuro abnormality eg encephalitis, birth asphyxia
epilepsy - investigations
EEG
MRI
first seizure clinic
epilepsy - management
by brand. usually started after SECOND epileptic seizure
generalised seizures - valproate
partial seizures - carbamazepine
DVLA, pregnancy, breastfeeding, contraception, other meds counselling
rescue meds for if seizures >5-10min
epilepsy + driving
first unprovoked / isolated seizure - 6mo off if NO abnormalities / epilepsy on imaging / EEG
otherwise - 12mo
12mo fit free if established epilepsy
don’t drive while meds being withdrawn + for 6mo after last dose
epilepsy meds + breast-feeding
generally safe
P450 enzyme inhibitors + inducers - epileptic meds
inhibitors:
valproate
inducers:
carbamazepine
phenytoin
