Epilepsy and black outs

Question 1

Key thing on making the diagnosis of epilepsy

Answer 1

HISTORY

Question 2

What can potentially increase th erisk of having a seizure

Answer 2

alcohol, illicit drug use, sleep deprivation,

Question 3

What to ask about i the history

Answer 3

What happened in the run up (last day and also just before the event) , during and also what happened afterwards.
ANY PREVIOUS EPISODES!

Things to look for
At the time: standing/postural change, pain, vomiting, passing urine, coughing, exercising

Just before: any warning symptoms eg palpatations/light headed/ odd taste/smell

During: Awareness, tongue biting, incontinance,

After: confusion, pain

WITNESS ACCOUNT!!

Question 4

If bitng tounguewhat do you wan tot find out?

Answer 4

Where on the tongue: sides are more common for a seizure whereas the tip of the toungue is more common in syncope

Question 5

Most common causes og black outs

Answer 5

Vasovagal (drop in bp) 20%
Unknown 34%
Reflex syncope 14%
Cardiogenic syncope (18%)

Question 6

What are the three categories of syncope?

Answer 6

Orthostatic - issue with fluid - dehydration/meds (antihypertensive), endocrine/autonomic

Cardiogenic - issue with heart of aorta - arrhythmias/aortic stenosis

Reflex (Neuro-cardiogenic) - issue with the situation - eg having blood taken/situation such as weeing (micturation)

Question 7

Why do we have syncope?

Answer 7

Caused by lack of blood flow in the brain and so if we can faint and be lying down then it will be easier for that blood to reach the reach the brain

Question 8

Presentation of a syncope episode, the we do what?

Answer 8

Patient history of event (very detailed), witnes view (if there is one).

Examinations: heart sounds, pulse, postural bp.

ECG - look for heart block and QT ratio, may need a 24h ecg

Question 9

Cardiogenic syncop - what investigations and why

Answer 9

ensure to ask about any palpatations/chest pain/SOB in history. Check came around fairly quickly and if they felt clammy/sweaty

-Family history
-refer to cardiology urgently

Question 10

What is a pseudoseizure and what investigations would we do

Answer 10

Something that looks a bit like a seizure but in fact have no crazy brain activity that you see in epileptic seizures. Often due to stressors or triggers and are more psychological.

Good history- self and witness.
Ideally you want an EEG capturing a typical episode

Question 11

Wat are common things that can provoke seizures?

Answer 11

Withdrawl (Alcohol/stroke)

head injury (within days)

stroke/neurosurgery (within 24h)

Severe electrolyte disturbance

Eclampsia

Question 12

What is epilepsy?

Answer 12

Tendency for unprovoked seizures

Due to disrupted background electrical activity of neurones

Question 13

What can be indicating factors of subsequent siezures after 1 siezure? (And diagnosis of epilepsy can be made?)

Answer 13

Stroke/tumour in area of brain

abnormality on EEG (spike and wave)

Question 14

What can cause seizures?

Answer 14

Something that can cause disturbance to the background activity of the neurones, soooooo….:

-Too much activity (ion channnel issues/glutamate issues or excititory amino acids)

-Too little activity (gaba receptor issues)

-Stroke/trauma/tumour/developmental causes

Question 15

Factors in epileptic patients that can cause seizure risk

Answer 15

-stress/anxiety
-missing meds
-sleep disturbance/fatigue
-hormonal changes
-drug/alcohol interactions
-some patients are photosensitive

Question 16

What do the main seizure/epileptic rugs ia to do?

Answer 16

dampen down the neuronal synapses. Notably Valproate qwhich increases the GABA turnover, decreases the Na channels and NMDA receptors

Question 17

What are the 2 groups of epi;e[s

Answer 17

Focal and generalised

Focal = focal part of the brain that is involved, more specific, might get an auora, cna become secondary generalised.

Generalised is the whole of the brain, may just be the whole of the brain from the onset or it could start in one particular location and rapidly spread across the whole of the brain. Give your typical Myoclonic seizures. More commonly diagnosed in children. No warning. Possible family history

Question 18

Tonic conic seizure, usually is indicative of what type of seizre

Answer 18

Tonic (stiffening) clonic (jerking) is the typical seizure you might think of. Is an unpredictable generalised seizure, although might be irritable before the seizure occuring.

PMH -complications at birth, Feb conv, trauma, menigitis, brain injuries

Question 19

Complex partial siezure

Answer 19

Temporal lobe seizure

History preceding events:
-Rising feeling in stomach,
-Funny smell/taste
-De ja vu (familiar experience)

No recollection of seizure - but from witess will be staring
blankly into space, might pick clothes and smakc lips)

disorientated afterwards

Question 20

Clinical assesment of seizures

Answer 20

-Refer to first seizure clinic
- ECG, routine bloods (Glc)
-A+E will often arrange a CT

From Neurology clinic:
- MRI for focal lesion
- EEG (Usually in <40yrs)
- Anti-epileptic drugs
-Refer to Epilepsy nurse (post diagnostic information)
-Discuss driving (inform DVLA)

Question 21

What is Absence seizures and who do they present most in?

Answer 21

Mainly in children, unaware, but stare into space and stop what they are doing. Is a type of generalised seizure.

Question 22

frontal lobe seizures

Answer 22

“Brief, bizarre and motor”
Often confused with non-epileptic attacks

Question 23

What ages are we most likely to see people with epilepsy and having seizures? What can make it or common to develop epilepsy?

Answer 23

Children (due to discovering they have epilepsy and that sort of thing) and older people (due to strokes etc)

Much more common to develop epilepsy if they have learning difficulties

Question 24

SO general investigations: adulsts and younger people

Answer 24

Younger people - more likely to have generalised seizures and so an EEG - also might be able to treat the seizure and remove the bad area through surgery

Adults - more likely to have focal seizures and so often a CT willl be performed to rule out more sinister and then likely to have an MRI

Question 25

Treatment of seizures. First line for:
a) priary generalised epilepsies
b) partial and secondary genarlised seizures
c)absence seizures

Answer 25

a) Sodium Valporate (or Lamotrigine, Levetiracetam)

b)Lamotrigine (or Carbamazepine, Levetiracetam)

c)Ethosuximide

Question 26

What is the risk of:
Valporate
Carbamazepine
Lamotrigine
Levetiracetam

Answer 26

Sodium Valproate = weight gain, possibly teratogenic, tremor, ataxia, nausea, pancreatitis, hepitits

Carbamazepine - ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash.

Lamotrigine (infected limosine ) –skin rash, difficulty sleeping

Levetiracetam – (doesn’t levetate your mood) irritability, depression

Question 27

What is Status Epilepticus

Answer 27

Generalised convulsive or non-convulsive seizures going on for 5 minutes or more either continuously or repetitively with no intervening recovery

Question 28

Status Epilepticus treatment

Answer 28

Midazolam (you give it MID seizure) 10mg buccal/intra nasal, repeated after 10 mins

OR

Lorazepam (when you’re on the fLOR): 0.07mg/kg, usually 4mg bolus repeated once after 10 mins

(Second line
Valproate – 30mg/kg iv over 10 mins. Max 3000mg (avoid in women of child-bearing age)
Levetiracetam 30mg/kg over 10mins. (Other guidelines go up to 60mg/kg). Max is 4500mg
Phenytoin - 20mg/kg, at 50mg/min (maximum 2g)
Third line
Anaesthesia usually with propofol or thiopentone)

Question 29

Can epileptic patients drive?

Answer 29

only 1 seizure and normal investigations: group 1 after 6 mo. group 2 afte 5 years

Epilepsy diagnosis:
Awake Seizure free for a year
If ever have had sleep seizures, must have had 3 years of sleep seizures only

Need to wait 6 months after medicine withdrawal before starting to drive again

To drive HGV need to be seizure free and on NO MEDS for 10 years. (if experienced seizure after the age of 5)