Epilepsy Flashcards
what questions must you ask to asses an episode of collapse?
Patient account History preceding events-stimulus, context Context/timing Posture History of event itself Warning symptoms-feel lightheaded Level of awareness/recollection Afterwards First recollection Seizure markers- prolonged disorientation, tongue biting, incontinence, muscle pains Witness account (ALWAYS TRY AND GET THIS) How were they before? Context 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 3 categories of syncope, and what are each of their causes?
Reflex (neuro-cardiogenic):
Taking blood/medical situations
Cough, Micturation
Orthostatic:
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
Cardiogenic:
Arrhythmia, aortic stenosis
What assessments must be completed if a patient has had syncope?
Examination Heart sounds, pulse Postural BPs Must have 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
what is the patients account for a cariogenic syncope>
History preceding events On exertion History of event itself Chest pain, palpitations, SOB Afterwards Chest pain, palpitations, SOB Came round fairly quickly Recovery may be longer Clammy/sweaty
Witness account (ALWAYS TRY AND GET THIS) Description of episode Suddenly went floppy Looked grey/ashen white Seemed to stop breathing Unable to feel a pulse There may have been a few brief jerks Variable duration of LOC Rapid recovery
how to assess a patient with cariogenic syncope?
Family history important Examination Heart sounds, pulse Must have ECG Look for heart block QT ratio Refer to cardiology urgently/admission for telemetry May need 24hr ECG/ECHO/prolonged monitoring
what is epilepsy?
Epilepsy is the tendency to recurrent seizures
what can cause a provoked seizure?
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 2 classifications of seizure?
generalised seizures and focal seizures
what are the subtypes in generalised seizures?
Absence seizures Generalised tonic-clonic seizures Myoclonic seizures Juvenile myoclonic epilepsy Atonic seizures
what are the subtypes in focal seizures?
Simple partial seizures
Complex partial seizures
Secondary generalised
Or by localisation of onset (temporal lobe, frontal etc
symptoms on primary generalised
No warning < 25 years May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy Generalised abnormality on EEG May have family history
symptoms of focal/partial>
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
Generalised Tonic clonic seizure- history and patient account?
Patient account
History preceding events
Unpredictable, tend to cluster
PMH- complications at birth, Feb conv, trauma, menigitis, brain injuries
History of event itself
May have vague warning
Irritability before them
Afterwards
Lateral (severe) Tongue biting, incontinence
First recollection in ambulance or hospital
Muscle pain
Witness account (ALWAYS TRY AND GET THIS)
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
who can get absence seizures? can they be provoked? what are the notable features?
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
May have eye-lid fluttering
Re-start what they were doing
juvenile cyclonic 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 Brief jerks in limbs
patient account of complex partial seizures? witness account?
Patient account 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
witness:Sudden arrest in activity Staring blankly into space Automatisms Lip smacking Repetitive picking at clothes
May be disorientated for a spell afterwards
how to do a clinical assessment of a seizure?
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)
incidence and prevalence of Epilepsy?
Incidence: 50 - 120 per 100 000 per year
“J-shaped” curve
3 - 5% of the population will experience at least one seizure in their lifetime
Prevalence: 5 – 8 per 1000 (Aberdeen 0.9%)
22% of patients with LD have Epilepsy
There are over 300 000 people in the UK with active epilepsy
investigations to do for a seizure?
EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
Video-telemetry if uncertainty about diagnosis
what are the factors influencing seizure risk?
Missed medications (most common)
Sleep disturbance, fatigue
Hormonal changes
Drug/alcohol use, drug interactions
Stress/Anxiety
Photosensitivity in a small group of patients
Other rarer reflex epilepsies (patterns, noise)
First line of treatment for epilepsy?
acutely?
Sodium Valproate, Lamotrigine, Levetiracetam for primary generalised epilepsies
Lamotrigine, Carbamazepine, Levetiracetam for focal and secondary generalised seizures
Ethosuximide for absence seizures
Acutely
Lorazepam, midazolam (diazepam) first line:
Valproate or phenytoin second line for status epilepticus
second line of treatment of generalised epilepsy?
Topiramate
Zonisamide
Clobazam
second line of treatment for partial seizure?
Sodium valproate -Topiramate -Gabapentin -Pregabilin -Zonisamide -Lacosamide -Perampanel Long acting Benzodiazepines (Clobazam) Vigabatrin
side affect of therapy?
Phenytoin – Arrythmia, hepatitis, medication interactions
Sodium Valproate - tremor, weight gain, ataxia, nausea, drowsiness, hepatitis
Try and avoid in women of childbearing age
Carbamazepine - ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash.
Lamotrigine –skin rash, difficulty sleeping
Levetiracetam – irritability, depression
