Epilepsy Flashcards
What two people will you ask to assess the episode of collapse?
- Patient account
2. Witness account (always try and get this)
What do you ask the patient to assess the episode of collapse?
History preceding events;
• Content/timing
• Posture
History of event itself;
• Warning symptoms
• Level of awareness/recollection
Afterwards;
• First recollection
• Seizure markers - prolonged disorientation, tongue biting, incontinence, muscle pains
What do you ask the witness to assess the episode of collapse?
How were they before? Description of episode; • Eyes open or closed • Description of abnormal movements • Pallor, alteration in breathing pattern, pulses • Duration of LOC • tiME TO RECOVERY
What are the three categories of syncope?
- Reflex (neuro-cardiogenic)
- Orthostatic
- Cardiogenic
Describe reflex syncope
Occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly.
Describe orthostatic syncope
Postural hypotension which can be caused by;
• Dehydration, medication related (anti-hypertensive)
• Endocrine, ANS
What are causes of cardiogenic syncope?
Arrhythmia (alters cardiac output) or aortic stenosis
Name some warning signs a person might get leading up to a syncopal episode
- Lightheaded
- Clammy
- Vision blacking out
What might a patient describe after a syncopal episode?
- Very brief loss of consciousness (LOC)
- Came round as I hit ground with friend standing over them
- Fully orientated quickly
- Clammy/sweaty
- Urinary incontinence
What might a witness describe after the syncopal episode?
- Looked a bit pale
* Suddenly went floppy (pale, few brief jerks, brief LOC)
What investigations are used to assess syncope?
Examination:
• Heart sounds, pulse
• Postural BPs
ECG
• Look for heart block
• QT ratio
May need 24hr ECG
• See cardiology if recurrent (5 day recordings)
• Consider Tilt table
Describe a patient account of a cardiogenic syncope
History preceding events:
• On exertion
History of event itself;
• Chest pain, palpitations, SOB
Afterwards;
• Chest pain, palpitations SOB
• Came around quickly
• Clammy/sweaty
Describe a witness account of a cardiogenic syncope
Description of episode; • Suddenly went floppy • Looked grey/ashen white • Seemed to stop breathing • Unable to feel a pulse (may have been few brief jerks, variable duration of LOC)
What is used to assess cardiogenic syncope
- FH important - heart problems
- Examination of heart sounds, pulse
- Must have ECG (heart block, QT ratio)
- Refer to cardiology urgently/admission for telemetry
- May need 24hr ECG/ECHO/prolonged monitoring
What is epilepsy?
The tendency to recurrent unprovoked seizures
What is the physiology behind epilepsy?
Our neurones have background electrical activity. If this is disrupted it can lead to a seizure.
How is a person’s seizures considered epilepsy?
The term Epilepsy is used if patients have more than one unprovoked seizure. Can also be used after a single seizure if investigations suggest a tendency to recurrence (i.e. abnormality on imaging - stroke, tumour)
What are seven causes of provoked seizures
- 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 are the two classifications of epileptic seizures?
Generalised and focal
Name five types of generalised epilepsies
- Absence seizures
- Generalised tonic-clonic seizures
- Myoclonic seizures
- Juvenile myoclonic epilepsy
- Atonic seizures
Name four types of focal epilepsies
- Simple partial seizures
- Complex partial seizures
- Secondary generalised
- Or by localisation of onset (temporal lobe, frontal etc)
What are primary generalised epilepsies?
- No warning
- < 25 yrs old
- May have history of absences and myoclonic jerks as well as generalised tonic-clonic seizures i.e. in juvenile myoclonic epilepsy
- Generalised abnormality on EEG
- May have family history
What are focal epilepsies?
- May get an “aura”
- Any age – cause can be any focal brain abnormality
- Simple partial and complex partial seizures can become secondarily generalised
- Focal abnormality on EEG
- MRI may show cause
Describe the patient account of Generalised Tonic Clonic Seizure
History preceding events;
• Unpredictable, tend to cluster
• PMH - complications at birth, trauma, meningitis, brain injuries
History of event itself;
• May have vague warning - irritability before
Afterwards;
• Lateral (severe) tongue biting, incontinence
• First recollection in ambulance or hospital
• Muscle pain
Describe the witness account of Generalised Tonic Clonic Seizure
- Groaning sound
- Tonic (rigid phase) - then generalised jerking in all four limbs
- Eyes open - staring/ roll upwards
- Foaming at the mouth
- Jerking for a few minutes and then groggy for 15-30mins
- May be agitated afterwards
- May have a cluster of episodes, stopping and starting
What are the features of absence seizures?
- Often in children (unaware of them)
- May be provoked by hyperventillation/ Photic stimulation (light through trees while in car)
- Sudden arrest of activity for a few seconds - brief staring or may have eye-lid fluttering
- Re-start what they were doing, unaware of what happened
What are the features of Juvenile myoclonic epilepsy?
- Adolescence/early adulthood - provoked by alcohol, sleep deprivation
- Can have absence and GTC seizures
- Will often have early morning myoclonus - drop things in the mornings and brief jerks in limbs
Describe the patient account of complex partial seizures (temporal lobe seizure)
History preceding events;
• Rising feeling in stomach, Funny smell/taste
• De ja vu (familiar experience)
History of event itself;
• No recollection
Afterwards;
• Disorientated for a spell
Describe the witness account of complex partial seizures (temporal lobe seizure)
- Sudden arrest in activity
- Staring blankly into space
- Automatisms - lip smacking and repetitive picking at clothes
May be disorientated for a spell afterwards
What are the steps in the clinical assessment seizures?
- Refer to first seizure clinic
- Do an ECG, routine bloods (Glc)
- A+E will often arrange a CT
From Neurology clinic: • May arrange an MRI for focal lesion • May arrange EEG (Usually in <40yrs) • Discuss Anti-epileptic drugs • Refer to Epilepsy nurse (post diagnostic information) • Discuss driving (inform DVLA)
When are EEGs used to investigate epilepsy?
For primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
When are MRIs used to investigate epilepsy?
For patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
When is video-telemetry used to investigate epilepsy?
Uncertainty about diagnosis
Name six factors which influence seizure risk
- Missed medications (most common)
- Sleep disturbance, fatigue
- Hormonal changes
- Drug/alcohol use, drug interactions
- Stress/Anxiety
- Photosensitivity (rarer)
What is the first line therapy for primary generalised epilepsies?
- Sodium Valproate
- Lamotrigine
- Levetiracetam
What is the first line therapy for focal and secondary epilepsies?
- Lamotrigine
- Carbamazepine
- Levetiracetam
What is the first line therapy for absence seizures?
Ethosuximide
What are the first and second line acute therapies for epilepsy?
First line:
Lorazepam, midazolam (diazepam)
Second line:
Valproate or phenytoin
What are the drugs used for second line treatment of generalised epilepsy?
- Topiramate
- Zonisamide
- Clobazam
What are the drugs used for second line treatment of partial epilepsy?
- Sodium valproate
- Topiramate
- Gabapentin
- Pregabilin
- Zonisamide
What are the side effects of use of phenytoin therapy?
Arrythmia, hepatitis, medication interactions
What are the side effects of use of sodium valproate therapy?
Tremor, weight gain, ataxia, nausea, drowsiness, hepatitis
Try and avoid in women of childbearing age
What are the side effects of use of carbamazepine therapy?
Ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash
What are the side effects of use of lamotrigine therapy?
Skin rash, difficulty sleeping
What are the side effects of use of levetiracetam therapy?
Irritability, depression
What are the driving regulations for someone with epilepsy?
After a single seizure, a patient may drive a car after 6 months if their investigations are normal and they have had no further events.
Patients with epilepsy can drive a car once they have been seizure free for a year or have only had seizures arising from sleep for a year.
What is status epilepticus?
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
Usually occurs in patients with no previous history of epilepsy (stroke, tumour, alcohol)
What is the first line treatment of status epilepticus?
- Midazolam
- Lorazepam
- Diazepam
What is the second and third line treatment of status epilepticus?
Second line:
Phenytoin, valproate
Third line:
Anaesthesia usually with propofol or thiopentone
What are the outcomes of status epilepticus?
- Mortality - highest n very young and old
* Avoid secondary damage - neurological problems
Describe the patient account of non-epileptic attack/pseudoseizure
History preceding events;
• Events may occur at times of stress or while at rest
History of event itself;
• May recall what people said during episode
• May be prolonged episode
• May describe dissociation
Describe the witness account of non-epileptic attack/pseudoseizure
• Stress trigger
• Signs of patient retaining awareness
- Tracking eye movement, still some verbalisation
- Movement not typical of seizures (pelvic thrusting, asynchronous movements, tremor)
Try to capture episode of EEG
