Epilepsy & management of convulsions / anticonvulsants Flashcards
what is a seizure
Seizure is a sudden change in behaviour caused by electrical hyper synchronization of neuronal networks in the cerebral cortex
difference between provoked and unprovoked seizure
unprovoked is unknown
provoked is drug or alcohol, stroke, encephalitis and acute head injury
encephalitis
what is it
symptoms
Encephalitis is inflammation of the active tissues of the brain caused by an infection or an autoimmune response. The inflammation causes the brain to swell, which can lead to headache, stiff neck, sensitivity to light, mental confusion and seizures.
vomiting
what is epilepsy
Epilepsy is more than 2 unprovoked seizures occurring within a 24 hour apart
1 unprovoked seizure and a problability of further seizure similar to general recurrence risk after 2 unprovoked ( eg more than 60%) occurring over the next 10 years
Diagnosis of an epilepsy syndrome
two main types of seizures
focal
generalsied
what is a focal seizure
very small area
origin in one hemisphere
first line for focal seizures
carbamazepine
Binds to sodium channels increases their refractory period
what is a generalised seizure
bigger
both hemipspheres - bilateral discharges involve subcortical structures
impairment of conciseness
examples include , absence, myoclonic, atonic( lose muscle power) , clonic, tonic( stiff) and tonic/clonic
first line for generalised seizures
sodium valproate
- Case 1 Mr Myshkin experiences episodes of epigastric discomfort (‘like riding a rollercoaster’)
- He has episodes of staring into the middle distance. He smacks his lips during the events. (Automatism)
- He is sometimes confused for a minute after the event.
what seizure
temporal lobe seizure
Case 2
• Mrs Black has suffered from ‘giggling’ fits all her life
• She had an episode where this giggling led to her head jerking to the right
• Her right arm then jerked and then her right leg
• This lasted 1/2 min
• Afterwards her right arm and leg felt weak for a couple of hours
gelastic seizure
- starts with giggling
- Mr White has had 2 minute episodes of seeing multi-coloured flashing colours
- This is self limited and his vision returns to normal afterwards
simpel oral occipital seizure
Mrs Yellow gets episodes where her whole left side tingles and she feels pins and needles.
• This lasts for a few seconds and is then gone.
• Sometimes she cannot use her left side and it feels weak afterwards.
focal onset right sided parietal seizure
occipital seizure features
unformed images
flashing light to complex visual hallucinations
can go blindd
vision return to normal though
temporal
complex aura visceral disturbance memory supernatural automatism - stares into distance and loses himself
frontal
Jacksonian march
todds paralysis
fencing posture with contraleteal head movement
arm extension with flexion of ipsilateral arm
pariteal
Jacksonian march
paraethsia or tingling - all one side
generalise tonic clonic seizures present as
abrupt loss of consciousness
everything becomes stiff - tonic phase - eyes open and pupils dilated and teeth clenched and breath held
muscles then begin to jerk after the 1st minute - tongue biting and blood sputum and eyes rolled back
absence seizures usually during childhood 4-12
5-10 seconds of staring and Brough on by what
hyperventilation or phonic stimulus
myoclonic seizures - juvenile
are sudden generalised muscle contractions and arm jerks when do they occur
in the morning
lifelong treatment of antiepiletpics - develop tonic and clonic seizures
pneumonic for aetiology ( cause) of seizures
VITAMINS
Vascualr infections, trauma/toxins, autoimmune, metabolic imbalance, idiopathic , neoplasm, syndromes
diagnosis
presenting features investigations and Ddi- ECG
CCTv footage of it
Drug history – tramadol, neuroleptics, vasodilators, older anti-depressants and prolongation of QTc – amitriptyline
red flags to probable seizure events
Eyes open – eyes closed titely non epileptic
Tongue biting on side – indication of seizure
Cyanosis
Stertuous breathing- cannot breathe properly
Incontinence of urine (faeces)
Post Ictal recovery time - long
Post ictal state – all over pain, injuries, exhaustion
- 1 year old presents with;
- Single episode where the baby went limp and then shook all 4 limbs
- Has been having ‘sniffles’
- Lasted 20 minutes
- Had a temperature of 38.8
is this an epileptic fit
no pyrexial fit
- 12 year old was standing in assembly
- Felt hot and sleepy and had been standing for 30 minutes
- Fainted to the floor
- All limbs shook whilst on the floor
- Felt ok and back to normal afterwards
epileptic fit ?
no went back to normal very quickly
- 23 year old with a history of episodes where;
- Feel them come on as see flashing lights
- Get a bad headache at the back of her head
- Associated with visual disturbances (flashing lights and zigzags)
- Lasts hours and then goes
- Feels tired afterwards
- Has happened several times, normally with alcohol or poor sleep.
epileptic siezure ?
no classic migraine
• A 39 year old man walks up to the doctors station and says he is feeling like he is about to have a fit
- Slowly falls to the floor backwards
- Teeth clenched and eyes shut with all 4 limbs extended
- Shakes all 4 limbs and then clenches their teeth again
• Opens eyes to check if staff are attending
- Pelvic thrusting
- Bites the tip of the tongue
- Lasts 20 minutes
- Feels tearful afterwards
no psychical circumstance
attention seeking
differential diagnosis
syncope cardiac arrhymias non-epileptic attack malingering attack migraine
what segment of PQRST complex can indicate seizure
long QT - blackout
what drugs cause long QT interval
- Antiarrhythmic drugs
- Certain non-sedating antihistamines (eg, terfenadine and astemizole)
- Macrolide antibiotics
- Certain psychotropic medications
- Certain gastric motility agents (eg, cisapride, domperidone).
Usually give antiepileptic on 2nd seizure
driving what should happen if epileptic fit
Driving – everyone who has suffered an unprovoked seizure should contact the DVLA – and surrender their license until allowed to drive again
1st seizure – 6 months – 1 year off driving
HGV 1 seizure – 10 years off driving
Establish epilepsy – need to be seizure free for 12 months
SUDEP
sudden unexplained death in epilepsy
triggers of epilepsy
Alcohol (withdrawal) Drugs – Amphetamine, Ecstasy, Cocaine Drugs – enzyme inducers – can trigger quicker metabolism of anticonvulsantds so less essentially so seizure could occur Missed Anticonvulsants Pregnancy (part of eclampsia, 2 and third trimester (Enlarged volume of distribution) Infections – UTI/URTI Illness – poorly absorbed Anticonvulsants
prescriptions – amk
what should you during a fit
cushion head and remove glasses, lossen tight clothing , recovery position afterwards, record time of seizure , don’t put anything in mouth not even to hold tongue , look for ID , don’t hold down ,as seizure ends offer help
recuse therapy for epilepsy
buccal midszolam ( date rape drug) or rectal diazepam
status epilepticus
over 5 mins of continuous seizures or over 2 discrete seizures between which there is an incomplete recovery of consciousness
what do you give during status epilepticus
diazepam 10-20mg repeated once 15 mins later - pre hospital
if easy lorazepam IV
established phenytoin infusion
for seizures you can always have surgery
hemispherectomy - outer layer of brain removed
corpus collostomcy
lobe removals or lobectomy bits of it
