Epilepsy Flashcards
What is epilepsy?
Recurrent spontaneous, intermittent, abnormal hyper proliferation of neurones → seizures
What are the 2 main types of epilepsy? How are these further divided?
- Generalised: Myoclonic, Tonic, Clonic, Tonic-Clonic, Atonic, Absence
- Focal/Partial: Simple, Complex
What is the criteria needed to diagnose epilepsy?
> 2 seizures >2weeks apart
Describe what myoclonic seizures look like
Shock like movement of one/several parts of the body
Describe what tonic seizures look like
Stiff sustained contractions
Describe what clonic seizures look like
Rhythmic jerking of one limb/side/whole body
Describe what tonic-clonic seizures look like
Stiffness + rhythmic jerking
Associated w/post-ictal confusion & drowsiness
Describe what atonic seizures look like
Myoclonic jerks
Sudden loss of muscle tone → fall to floor
NO loc
Describe what absence seizures look like
Abrupt psychomotor arrest (5-15secs)
Upward deviation of eyelid
Perioral myoclonus (mouth twitching)
Describe a simple seizure
AKA Focal Aware seizure
No post-ictal Sx
Awareness intact
Focal motor, sensory, autonomic, psych Sx
Describe a complex seizure
AKA Focal Unaware seizure Awareness impaired Post-ictal Sx OR rapid recovery Sx: Lip-smacking, grunting CAN BECOME A GENERALISED SEIZURE
What auras are there pre-seizure?
TEMPORAL: COMMON Gastric discomfort, anxiety, hallucinations, memory disturbance, lip smacking, head turning
OCCIPITAL: Multi-coloured bright lights spreading from one homonymous field, flashes, floaters
FRONTAL: Dystonic posture w/rapid recovery
CENTRO-PARIETAL: C/L paraesthesia (pain, tingling, numb) spreads from 1 limb to 1 side
How is epilepsy investigated?
ECG: Arrhythmia/ Long QT
EEG +/- sleep-deprived EEG
MRI/CT: NOT ROUTINELY DONE- New diagnosis → exclude infective/vascular causes
Bloods: Find causes- U&E, Ca, Glucose
When is an EEG indicated?
> 2 seizures
OR
1 seizure if considered necessary by neurologist
Is an EEG helpful in the diagnosis of epilepsy?
Support diagnosis
Cannot exclude/refute epilepsy
Use photic/hyperV techniques to provoke seizure
Often just done for generalised/status
When should an epileptic be referred to secondary care?
All patients with diagnosis
Re-refer if seizure not controlled or dose change
When should an epileptic be referred to tertiary care?
Seizures not controlled Drugs ineffective Child <2yo Structural lesion Diagnostic doubt ACCESS GIVEN TO ALL PATIENTS WITH EPILEPSY
How is epilepsy managed?
1) Anti-epileptic: After diagnosis confirmed/ usually after 2nd seizure
2) Med fail: Surgical resection/ Vagal nerve stimulation
3) Ketogenic diet, deep brain stimulation
What anti-epileptics are given for the different types of seizures?
- Myoclonic: 1) Sodium Valproate 2) Kepra
- Focal: Carbamazepine or Lamotrigine
- Absence/tonic-clonic/atonic: 1) Sodium Valproate, 2) Lamotrigine
When is Sodium Valproate contraindicated?
Woman of child bearing age/sexually active
Pregnant
Give Lamotrigine
What is the pathway for giving/changing AEDs?
Monotherapy → ↑dose of maximal tolerated → switch to 2nd line → combine
When should you consider stopping an AED?
> 2years seizure free
Wean down over 3months
What needs to be reviewed an an annual epilepsy review?
- Seizure diary: no. frequency, date of most recent, type
- Meds: Name, dose, adherence, SE, cognitive problems, effect, adjust dose if needed
- Bloods: Folate, Vit D, FBC
- Lifestyle: Driving, contraception, pregnancy planning, employment
What is the prognosis of epilepsy?
90% absence fits in children resolve
60-70% seizure free
What is a major complication of epilepsy?
SUDEP- sudden unexpected death in epilepsy
Common in uncontrolled epilepsy
Related to nocturnal seizure associated w/apnoea or asystole
What are the DVLA rules related to epilepsy?
Car/motorcycle: Eligible if seizure free for one year If seizure no driving for 6m Lorry/bus: Seizure free for 10years No AEDs in 10years One off seizure no driving for 5years
What are the causes of status epilepticus?
Idiopathic Stroke Epilepsy: Precipitated by med withdrawal OH- Infection & tumours Hypoxia Drugs of abuse Hypoglycaemia Metabolic (hypoNa, hypoCa)
What are the worrying features of status?
Preceding headache/ head injury Duration >5mins Prolonged post-ictal phase Adult onset Recent depression (?OD)
What is Todd’s paresis?
Focal weakness in a part or all of the body after a seizure
What investigations should be done in status?
Bloods: FBC, U&E, LFT, Glucose, ↓Ca2+, Mg2+, ↑/↓Na+, Cultures ABG Urine: Drug screen, bHCG ECG CT/MRI/LP
What is the management of status in the first 0-5mins?
SECURE AIRWAY 15L/O2 Nasopharyngeal Recovery position IV access at 3-4mins GLUCOSE: <3.5 = 100ml of 20% glucose STAT
What is the management of status in the first 5-20mins?
HELP- Notify anaesthetics & ICU Attach cardiac monitor Buccal Midazolam 10mg/ IV Lorazepam 4mg over 2mins/ Rectal Diazepam 10mg over 2mins REPEAT at >10mins OH-: Pabrinex 2 pairs IV over 10mins
What is the management of status in the first 20-40mins?
ANAESTHETICS Phenytoin 20mg/kg IV over 20mins (Need to monitor cardiac function & BP) OR Phenobarbital 10mg/kg IV over 10mins OR Valproate
What is the management of status in >40mins?
RSI
Thiopentone OR Propofol
ICU
How is status managed in a child?
5mins: Buccal midazolam/ PR Diazepam/ IV Lorazepam
15mins: IV Lorazepam over 2mins
25mins: IV Phenytoin
>45mins: RSI w/Thiopentone
What are the complications of status epilepticus?
Brain anoxia
Neuronal death w/permanent deficits
What should be done post-status?
Consider CT/LP
Tox screen
Blood levels of AEDs
Abx/Antivirals
