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Nervous System > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

Assessing Collapse Episodes (general = pt. recollection & witness account)

A

Patient Recollection:

a. HISTORY PRECEDING EVENT = CONTEXT/TIMING, POSTURE
b. HISTORY OF EVENT THEMSELVES = WARNING SYMPTOMS, LVL OF AWARENESS/RECOLLECTION
c. AFTERWARDS = 1ST RECOLLECTION, SEIZURE MARKERS (prolonged disorientation, tongue biting, incontinence, muscle pains)

Witness Account:

a. HOW WERE THEY BEFORE
b. DESCRIPTION OF EPISODE

i. EYES OPEN/CLOSED
ii. DESCRIPTION OF ABNORMAL MOVEMENTS
iii. PALLOR, ALTERATION IN BREATHING PATTERN, PULSES
iv. DURATION OF LOC TIME TO RECOVERY
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2
Q

Syncope Aetiology (SVNCOPE)

A

SITUATIONAL (post: micturition, defaecation, cough, swallow, prandial, exercise)

VASOVAGAL (taking blood, medical situations etc.)

NEUROGENIC

CARDIOGENIC (arrthymias, aortic stenosis)

ORTHOSTATIC (hypovolaemic: dehydration, antihypertensives; endocrine, ANS)

PSYCHOGENIC

ENDOCRINE (e.g. hypoglycaemia)

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3
Q

Main 3 Causes of Syncope

A

Neuro-cardiogenic
Orthostatic
Cardiogenic

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4
Q

Syncope Definition

A

Transient LOC from Global Cerebral Hypoperfusion (usually due to systemic hypotension)

LOC from systemic hypotension = rapid onset, short duration, rapid recovery

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5
Q

General Syncope History (before, during, after)

A

Before:

STIMULUS/TRIGGER: blood being drawn, defaecation etc.

CONTEXT: only in bathroom, only when standing up etc.

During:

LOSS OF CONSCIOUSNESS = RAPID ONSET + TRANSIENT

WARNING SYMPTOMS/PRODROME = LIGHTHEADED, PALE, CLAMMY, VISION BLACKING OUT

MORE IMMEDIATE TRIGGERS

MAY HAVE URINARY INCONTINENCE, CLAMMY, SWEATY, CONVULSIONS

After:

SPONTANEOUS & COMPLETE RECOVERY

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6
Q

General Syncope Investigations

A

EXAMINATION: HEART SOUNDS, PULSE, POSTURAL BPs

ECG: look for HEART BLOCK, QT RATIO

May need 24HR ECG + may need to see CARDIOLOGY IF RECURRENT (5 day recordings, reveal devices

CONSIDER TILT TABLE

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7
Q

Cardiogenic Syncope (pt. recollection & witness account)

A

Patient Recollection:

BEFORE:

ON EXERTION

DURING:

CHEST PAIN, PALPITATIONS, SOB

PALE, CLAMMY/SWEATY

AFTER:

CHEST PAIN, PALPITATIONS, SOB
CLAMMY/SWEATY

REGAINS CONSCIOUSNESS QUITE QUICKLY (recovery may talk longer”

Witness Account:

EPISODE DESCRIPTION:

SUDDEN FLOPPINESS (LOSS OF MUSCLE TONE)

Turned GREY/ASHEN WHITE

Seemed to STOP BREATHING

UNABLE TO FEEL PULSE

Poss. FEW BRIEF JERKS
VARIABLE DURATION OF LOC
    RAPID RECOVERY
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8
Q

Cardiogenic Syncope Investigations

A

HISTORY (FHx) & EXAMINATION (HS, PULSE)

ECG (HEART BLOCK, QT RATIO)

REFER TO CARDIOLOGY URGENTLY/ADMISSION FOR TELEMETRY

May need 24HR ECG/ECHO/PROLONGED MONITORING

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9
Q

Epilepsy Definition

A

TENDENCY TO RECURRENT SEIZURE

> 1 UNPROVOKED SEIZURE or AFTER SINGLE SEIZURE IF INVESTIGATIONS SUGGEST TENDENCY T RECUR (> 60% risk of recurrence over 10yrs)

e.g. ABNORMALITY ON IMAGING = stroke, tumour; ABNORMALITY ON EEG (spike & wave)

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10
Q

Seizure Pathophysiology

A

DISRUPTED BACKGROUND NEURONAL ELECTRICAL ACTIVITY

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11
Q

Seizure Classification (generalised & focal)

A

Generalised:

  • ABSENCE SEIZURES
  • GENERALISED TONIC-CLONIC SEIZURES
  • MYOCLONIC SEIZURES
  • JUVENILE MYOCLONIC EPILEPSY
  • ATONIC SEIZURES

Focal:

  • SIMPLE PARTIAL SEIZURES
  • COMPLEX PARTIAL SEIZURES
  • SECONDARY GENERALISED
  • Or by LOCALISATION OF ONSET (e.g. temporal lobe, frontal lobe
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12
Q

Provoked Seizures

A
  • ALCOHOL WITHDRAWAL
  • DRUG WITHDRAWAL
  • W/I FEW DAYS AFTER HEAD INJURY
  • W/I 24HRS OF STROKE
  • W/I 24HRS OF NEUROSURGERY
  • WITH SEVERE ELECTROLYTE DISTURBANCE
  • ECLAMPSIA
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13
Q

Epilepsy Hx (primary generalised vs. focal/partial)

A

Primary Generalised:

  • NO WARNING
  • < 25YRS
  • May have Hx of ABSCENCES & MYOCLONIC JERKS & GTCS (e.g. in juvenile myoclonic epilepsy)
  • GENERALISED ABNORMALITY ON EEG
  • MAY HAVE FHx

Focal/Partial:

  • May get an “AURA”
  • ANY AGE (due to ANY FOCAL BRAIN ABNORMALITY)
  • SIMPLE PARTIAL & COMPLEX PARTIAL SEIZURES = CAN BECOME SECONDARY GENERALISED
  • FOCAL ABNORMALITY ON EEG
  • MRI MAY SHOW CAUSE
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14
Q

Generalised Tonic-Clonic Seizure Hx (pt. recollection & witness account)

A

Patient Recollection:

BEFORE:

UNPREDICTABLE, TEND TO CLUSTER

PMH = BIRTH COMPLCATIONS, FEBRILE CONVULSIONS, TRAUMA, MENINGITIS, BRAIN INJURIES

DURING:

Poss. have VAGUE WARNING

PRIOR IRRITABILITY

AFTER:

LATERAL SEVERE TONGUE BITING

INCONTINENCE

1ST RECOLLECTION IN AMBULANCE/HOSPITAL (prolonged disorientation, fatigued, headache)

MUSCLE PAIN

Witness Account:

GROANING SOUND

TONIC (RIGID PHASE) + then GENERALISED JERKING IN ALL 4 LIMBS

EYES OPEN = STARING/ROLL UPWARDS

FOAMING AT MOUTH

JERKING FOR A FEW MINS + then GROGGY FOR 15-30MINS

May be AGITATED AFTERWARDS
    May have CLUSTER OF EPISODES, STOPPING &amp; STARTING
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15
Q

Absence Seizure Hx

A

OFTEN CHILDREN

Poss. TRIGGERS: HYPERVENTILATION/PHOTIC STIMULATION (light through tree while in car etc.)

SUDDEN ARREST IN ACTIVITY FOR FEW SECS = BRIEF STARING, EYELID FLUTTERING, poss. SLIGHT JERKING

RESTART WHAT THEY WERE PREVIOUSLY DOING, NO REMBRANCE OF SEIZURE

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16
Q

Juvenile Myoclonic Epilepsy Hx

A

ADOLESCENCE/EARLY ADULTHOOD

Provoked by SLEEP DEPRIVATION, ALCOHOL

CAN HAVE ABSENCE & GTC SEIZURES (tend to occur in morning)

WILL OFTEN HAVE EARLY MORNING MYOCLONUS

Drop things in the mornings Brief jerks in limbs
17
Q

Complex Partial Seizure Hx: Temporal Lobe Seizures (pt. recollection & witness account)

A

Patient Recollection:

BEFORE:

• AURA: rising feeling in stomach, unusual smell/taste, déjà  vu

DURING:

• NO RECOLLECTION

AFTER:

• DISORIENTATED FOR A WHILE

Witness Account:

• SUDDEN ARREST IN ACTIVITY

  • STARING BLANKLY INTO SPACE
  • AUTOMATISMS
    • LIP SMACKING
    • REPETITIVE PICKING AT CLOTHES

• DISORIENTED FOR A WHILE

18
Q

Seizure Investigations:

A

REFER TO 1ST SEIZURE CLINIC

ECG + ROUTINE BLOODS (Glc)

CT (often arranged by A+E)

VIDEO-TELEMETRY IF UNCERTAIN ~ DIAGNOSIS

FROM NEUROLOGY CLINIC:

○ MRI = FOCAL LESION
○ EEG (usually < 40yrs, usually after 2nd seizure)
○ DISCUSS ANTI-EPILEPTICS DRUGS
○ REFER TO EPILEPSY NURSE (post diagnostic info)
○ DISCUSS DRIVING (inform DVLA)
19
Q

Epilepsy Management (1st line for primary generalised, focal/partial & secondary seizures, absence, acutely)

A

Primary Generalised Epilepsies:

  • SODIUM VALPROATE
  • LAMOTRIGINE
  • LEVETIRACETAM

Focal/Partial & Secondary Seizures:

  • CARBAMAZEPINE
  • LAMOTRIGNINE
  • LEVETIRACETAM

Absence:

• ETHOSUXIMIDE

20
Q

Medication Side Effects (sodium valproate, lamotrignine, levetiracetam, carbamazepine, phenytoin)

A

Sodium Valproate:

  • TREMOR
  • WGT. GAIN
  • ATAXIA
  • NAUSEA
  • DROWSINESS
  • HEPATITIS
    • Try to avoid in women of childbearing age

Lamotrignine:

  • SKIN RASH
  • SLEEP DIFFICULTIES

Levetiracetam:

  • IRRITABILITY
  • DEPRESSION

Carbamazepine:

  • ATAXIA
  • DROWSINESS
  • NYSTAGMUS
  • BLURRED VISION
  • LOW SERUM Na+ LVLS
  • SKIN RASH

Phenytoin:

  • ARRTHYMIA
  • HEPATITIS
  • MEDICATION INTERACTIONS
21
Q

Status Epilepticus Definition

A
  • PROLONGED/RECURRENT TONIC-CLONIC SEIZURES
    • PERSISTING > 30 MINS
    • NO RECOVERY PERIOD BWTN SEIZURES○ BE WARY OF NON-CONVULSIVE STATUS EPILEPTICUS (prolonged unresponsiveness following seizure)
    • USUALLY OCCURS IN PT. W/ NO PREVIOUS HISTORY OF EPILEPSY (STROKE, TUMOUR, ALCOHOL)
22
Q

Status Epilepticus Management (1st, 2nd & 3rd line)

A

1st Line:

MIDAZOLAM
LORAZEPAM
DIAZEPAM

2nd Line:

PHENYTOIN
SODIUM VALPROATE

3rd Line:

ANAESTHETIC = PROPOFOL/THIOPENTONE

23
Q

Driving Regulations

A

Single Seizure:

> 6 MONTHS + NORMAL INVESTIGATIONS + NO FURTHER EVENTS = CAN DRIVE CAR

> 5 YEARS + NORMAL INVESTIGATIONS + NO FURTHER EVENTS + NOT ON ANTI-EPILEPTIC MEDS = CAN DRIVE HGV/PSV

Epilepsy:

> 1 YR SEIZURE-FREE /ONLY HAVE SEIZURES ARISING FROM SLEEP FOR 1 YR = CAN DRIVE CAR

IF DAYTIME SEIZURE OCCURS + PATTERN THEN BECOMES NOCTURNAL = ESTABLISHED FOR 3 YRS BEFORE THEY CAN DRIVE

> 10 YRS SEIZURE-FREE + NOT ON ANTI-EPILEPTIC MEDICATION = CAN HOLD HGV/PSV LICENSE

24
Q

Factors/Triggers Influencing Seizure Risk

A
  • MISSED MEDICATIONS (most common)
  • SLEEP DISTURBANCE, FATIGUE
  • HORMONAL CHANGES
  • DRUG/ALCOHOL USE, DRUG INTERACTIONS
  • STRESS/ANXIETY
  • PHOTOSENSITIVITY (in small group of pt.)
    • OTHER RARER RELFEX EPILEPSIES (PATTERNS, NOISE)
25
Q

Pseudoseizure Hx (pt. recollection & witness account)

A

Patient Recollection:

BEFORE:

* TRIGGERS: STRESS/WHILE AT REST
* Often give details of others reaction &amp; little of events

DURING:

* MAY RECALL WHAT PEOPLE SAID DURING EPISODE
* MAY BE PROLONGED EPISODE - WAXING &amp; WANING
* MAY DESCRIBE DISSOCIATION

AFTERWARDS:

• OTHERS REACTIONS

Witness Account:

  • MAY RECOGNISE STRESS AS A TRIGGER
  • MAY REPORT SIGNS OF PT. RETAINING AWARENESS
    • TRACKING EYE MOVEMENTS, SOME VERBALISATION DURING EPISODES
    • MOVEMENTS ATYPICAL OF SEIZURES = Pelvic Thrusting, Asynchronous Movements, Tremor, Waxing & Waning Episodes etc.

Nervous System (12 decks)

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