Epilepsy & LoC Flashcards by Jack Gorard

What are the classical features of a generalised (tonic-clonic) seizure?

Aura
LoC
Tonic phase (body rigid for 1min, tongue biting, incontinence)
Clonic phase (gen convulsion, frothing of mouth, rhythmic jerking, sev mins)
Post ictal phase (drowsiness/confusion/coma for sev hrs)

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What are the three main types of syncope?

Vasovagal/cardiogenic syncope
Post hypotension
Post-prandial hypotension

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What causes vasovagal syncope?

Due to sudden reflex bradycardia/peripheral vasodilation

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What are the features of vasovagal syncope?

Occurs in response to standing/fear/venesection/pain
Pt unconscious <2mins
Recovery rapid, no treatment required

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What is postural hypotension?

Drop in systolic BP of 20mmHg on standing from sitting/lying

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What causes postural hypotension?

Pooling of blood in legs due to gravity

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What factors increase the risk of postural hypotension?

Fluid depletion
Age-related autonomic dysfunction
Polypharmacy

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What is post-prandial hypotension?

Drop in systolic BP of 20mmHg (or diastolic of 10mmHg) after eating

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What causes post-prandial hypotension?

Pooling of blood in splanchnic vasculature

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What are the less common causes of syncope?

Carotid sinus syncope (excessive vagal response)
Anaemic syncope
Micturition syncope
Coughing/exertion syncope

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What features distinguish seizures from syncope?

Witness account of jerking movements, incontinence, post-episode confusion & amnesia = SEIZURE
Cardiac evaluation can detect risk factors for syncope

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What investigations are appropriate in a pt w/ recurrent syncope?

Bloods - FBC, U&amp;Es, glucose
Lying/standing BP, tilt-tabel tests
ECG/24hr tape (heart block, arrhythmias, long QT)
EEG
Echo/CT head

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What advice must be given to all pts w/ recurrent syncope?

Do not drive until cause found

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What is a seizure?

Convulsion/transient abnormal event resulting from paroxysmal discharge of cerebral neurones

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What is epilepsy?

Continuing tendency to have seizures even if a long time separates the attacks
Affects 1% of population

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What is a partial seizure?

Single focus of electrical activity

simple partial
complex partial

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What are the features of a simple partial seizure?

No impairment of consciousness, single limb jerking w/ sensory aura (pattern depends on lobe involved)

Temporal (lip smacking, chewing)
Frontal (motor movements, speech arrest, Jacksonian march)
Parietal (sensory disturbances, tingling/numbness
Occipital (visual disturbances)

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What are the features of a complex partial seizure?

Consciousness impaired at some stage

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What is Todd’s paralysis?

Temporary paresis of originally affected limb after a partial seizure

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What are the features of Temporal Lobe epilepsy?

Classical aura w/ sense of fear/deja-vu/hallucinations
Confusion/anxiety
Automatisms (lip smacking/chewing)

What are generalised seizures?

Widespread focus of electrical activity across both hemipsheres

absence
tonic-clonic
tonic
clonic
myoclonic
atonic

What are the features of absence seizures?

<10secs of LoC in 4-10yrs, more common in girls
Stimulated by hyperventilation/flashing lights
Remit by puberty, predispose to adult epilepsy

What are the features of tonic seizures?

Extended/flexed trunk

What are the features of clonic seizures?

Jerking

What are the features of myoclonic seizures?

Brief, shock like movements

What are the features of atonic seizures?

Sudden drop to the floor

What are the 2o causes of epilepsy?

Structural (trauma, SoL, stroke, SLE, AVMs) Developmental (CP) Metabolic -hypo/hyper (glycaemia, calcaemia, natraemia) -liver disease Drugs (withdrawal, cocaine, TCAs, SSRIs, ciprofloxacin) Infection (encephalitis, HIV, syphilis)

What is the immediate first aid treatment of a patient having a generalised seizure?

Place pt in recovery position Remove harmful objects in location Rectal dizepam

What should be done if the seizure lasts >3mins (status epilepticus)?

``` ABCDE IV Lorazepam (4mg bolus) Finger prick glucose (IV glucose 50ml of 50%) IV Pabrinex (if alcoholism) Preg test IV Phenytoin (if seizures persist, 15mg/kg) Continue intubation (anaesthetic review) CT/LPs/cultures ```

What are the possible causes of status epilepticus?

``` Epilepsy Hypoxia Stroke Brain injury Metabolic derangements Infections Eclampsia Drug withdrawal/toxicity ```

What is the prognosis of status epilepticus?

Mortality 10%

What investigations are appropriate in suspected epilepsy?

Bloods - FBC, U&Es, LFTs, Ca, Mg, glucose Head CT/MRI EEG

When is treatment for epilepsy started?

After two seizures, if organic causes ruled out

What is the goal of epilepsy treatment?

Control seizures w/ lowest possible dose w/ fewest side effects -achieved in 70%

What are the most common triggers for epileptic seizures?

``` Lack of sleep Alcohol/drugs Hypoglycaemia Caffeine Stress Flashing lights ```

What medications are used to treat generalised seizures?

1st line - Valproate, Lamotrigine (if female of childbearing age) Adjuncts - Clozabam, Carbamazepine, Levetiracetam Ethosuxamide if absence seizure

What medications are used to treat partial seizures?

1st line - Carbamazepine, Lamotrigine (if female of childbearing age) Multiple adjuncts used

How does Valproate work?

Potentiates GABA | Causes Na channel blockade

What are the common side effects of Valproate?

``` Rash/hair loss Sedation/wt gain Tremor Birth defects Thrombocytopenia Liver damage ```

How does Lamotrigine work?

Blocks Na channel | Reduces glutamate release

What are the common side effects of Lamotrigine?

Mild sedation | Bone marrow toxicity

How does Carbamazepine work?

Na channel blocker

What are the common side effects of Carbamazepine?

``` Rashes Dizziness Double vision Agranulocytosis Birth defects Liver damage Induces metabolism of itself/other drugs ```

How does Phenytoin work?

Voltage dependent blockage of Na channels

What are the common side effects of Phenytoin?

Gum growth Nystagmus Enzyme induction

Why does Phenytoin require therapeutic monitoring?

Zero order kinetics | Disproportionate increases in plasma concentration

What are the serious side effects common to all anti-epileptic drugs?

Leucopenia Rashes Steven-Johnson Syndrome Toxic Epidermal Necrolysis

When can drug withdrawal be considered?

Seizure free for 2-4 years - drug reduced in dose every 4wks - pt stopping driving during withdrawal

What are the current laws regarding epilepsy and driving?

Pts must tell DVLA immediately/stop driving if had a seizure -if pt was awake & LoC, license is revoked Pts can apply for a new license if no seizures for 6mo after 1 seizure -1yr after repeat attacks If sleep-related epilepsy can drive if only had seizures while sleeping for 3yrs