Epilepsy

Question 1

acute epilepsy - investigations

Answer 1

B - oxygen
C - BP + ECG
D - glucose, calcium, U+Es (derangements)
E - neuro exam (do urgent CT brain if abnormal)

Question 2

epilepsy counselling - what can increase seizure likelihood - what to avoid + what situations to be careful in

Answer 2

illness + vomiting drug
sleep deprivation
new medications/rec drugs
alcohol + next day
not eaten

Question 3

lamotrigine SEs

Answer 3

sedation/insomnia
dizziness
nausea

allergic skin rash
multisystem hypersensitivity - fever

Question 4

how should epilepsy be managed when planning pregnancy? (what to do before pregnant)

Answer 4

start lowest dose lamotrigine

prophylactic folic acid 5mg until trim 1 +

Question 5

when + how should epilepsy drugs be started? what to do if they fail?

Answer 5

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

Question 6

what are 1st and 2nd line drugs given in epilepsy?

Answer 6

1 - sodium valproate or lamotrigine (better tolerated/less teratogenic)
2 - carbamazepine or topiramate

Question 7

lamotrigine - SEs

Answer 7

rash/flu - stevens-johnson
fever - hypersensitivity

blurred/double vision
tremor
nausea + dizziness

Question 8

valproate SEs

Answer 8

hair loss
weight gain

teratogenicity
hepatotoxicity - monitor LFTs in 1st 6mo
cough, sore throat, bruising
extreme tiredness, abdo pain, jaundice

Question 9

breastfeeding + epilepsy meds

Answer 9

use lamotrigine only

Question 10

status epilepticus in pregnancy

Answer 10

eclampsia likely
check urine + BP
may need ASAP delivery

Question 11

status epilepticus - management overview

Answer 11

call ICU
ABCDE
rule out hypoxia + hypoglycaemia before ?other causes

Question 12

status epilepticus - investigations

Answer 12

A+ B - ABG, sats
C - cardiac monitor, FBC
D - glucose, U&E, calcium
E - consider LP, CT

Question 13

status epilepticus - management

Answer 13

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

Question 14

what to do if lorazepam bolus doesn’t work in status epilepticus?

Answer 14

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

Question 15

what does a pseudoseizure look like?

Answer 15

no response to diazepam infusion
pelvic thrusts
resisting your attempts to open lids/do passive movements
flailing limbs

Question 16

what to do when status epilepticus controlled

Answer 16

LP + MRI if indicated
start oral meds

identify cause:
drugs - alcohol/drugs/inadequate meds
illness - CNS lesion/infection
other - low glucose, pregnant

Question 17

seizure vs syncope

Answer 17

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

Question 18

generalised seizures - features + types?

Answer 18

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

Question 19

infantile spasms (west’s syndrome)

Answer 19

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

Question 20

epilepsy - investigations

Answer 20

EEG
MRI
first seizure clinic

Question 21

epilepsy - management

Answer 21

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

Question 22

epilepsy + driving

Answer 22

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

Question 23

epilepsy meds + breast-feeding

Answer 23

generally safe

Question 24

P450 enzyme inhibitors + inducers - epileptic meds

Answer 24

inhibitors:
valproate

inducers:
carbamazepine
phenytoin

Question 25

non-epilepsy syncope + DVLA

Answer 25

simple - fne
single, explained + treated episode - 4wk
single, unexplained - 6mo off
2+ episodes - 12mo off