Fits/ Epilepsy

Question 1

What is epilepsy?

Answer 1

Neuro condition characterised by 2 or more seizures

Question 2

What conditions are associated with epilepsy?

Answer 2

Cerebral palsy
Tuberous sclerosis
Mitochondrial diseases

Question 3

How can you classify epileptic seizures?

Answer 3

Primary generalised
Secondary generalised
Focal

Question 4

What is a primary generalised seizures?

Answer 4

Idiopathic juvenile epilepsy- whole brain is being affected
Underlying genetic basis, otherwise pts are normal with no structural brain abnormalities
Usually manifest in childhood and adolescence

Question 5

What is secondary generalised seizures?

Answer 5

Due to irritation/infection/inflammation of the cortex, or cortex needs something e.g oxygen, glucose, space

A focal seizure can progress to affect the whole brain–> secondary generalised seizure

Question 6

What are some types of generalised seizures?

Answer 6

Tonic clonic
Tonic
Clonic
Typical absence
Myoclonic
Atonic

Question 7

Describe a tonic clonic seizure

Answer 7

Loss of consciousness–> tonic phase: muscle tensing- whole body is rigid with jaw clenched
Clonic phase–> repetitive rhythmic jerking movements

Question 8

Features of tonic-clonic seizures?

Answer 8

Jaw clenched
lateral tongue biting
cyanosis
foaming at the mouth (may be blood stained)
Irregular breathing
may make a loud sound
confused, drowsy post-ictally
Incontinence

Question 9

Features of absence seizure?

Answer 9

typically happen in children
Blank stare into space, then abruptly returns to normal.
During the episode, won’t respond
Unaware they’ve had the seizure
Lasts around 10-20s

Question 10

Features of atonic seizure?

Answer 10

Known as ‘drop attacks’
Brief lapse in muscle tone
Usually last up to 3 mins

Question 11

Features of myoclonic seizure?

Answer 11

Sudden brief muscle contraction
Pt usually awake
Like a jerk
Typically occur in Juvenile myoclonic epilepsy

Question 12

What is Juvenile myoclonic epilepsy?

Answer 12

Typical onset in the teens, more common in girls
1. Infrequent generalized seizures, often in morning
2. Daytime absences
3. Sudden, shock like myoclonic seizure
usually good response to sodium valproate

Question 13

What is a focal seizure?

Answer 13

Usually arises from the temporal lobe and can affect M.E.S.H
M = memory
E = emotion
S = speech
H = hearing

IT DOES NOT INVOLVE THE WHOLE BRAIN

Question 14

How can a focal seizure present?

Answer 14

Deja vu
lip smacking
jamais vu
doing things on autopilot

Question 15

What is the post-ictal phase?

Answer 15

When a pt has just had a seizure, feels drowsy/unwell/tired 15-30mins

Question 16

Investigations post first seizure?

Answer 16

EEG and MRI

Question 17

What advice would you give to patients who have just had a/ first seizure?

Answer 17

Need to inform the DVLA- stop driving
Inform occupational health at their work place
No swimming, no heights
GP if they have further seizures
Call an ambulance if a further seizure lasts more than 5 mins

Question 18

Triggers for seizures in idiopathic juvenile epilepsy?

Answer 18

Binge drinking alcohol
Sleep deprivation

Question 19

Management for generalised seizures?

Answer 19

Sodium valporate or lamotrigine / levetiracetam in women of childbearing age

Question 20

Management for focal seizures?

Answer 20

1st line = Carbamazepine or lamotrigine
2nd line = sodium valproate or levetiracetam

Update: 1st line = lamotrigine or levetiracetam
2nd line = sod val or carbamazepine.

Question 21

Side effects of sodium valproate?

Answer 21

From Z2F - teratogenic, liver damage and hepatitis, hair loss, tremor

From BNf
increased appetite and weight gain
alopecia: regrowth may be curly
P450 enzyme inhibitor
ataxia
tremor
hepatitis
pancreatitis
thrombocytopaenia
teratogenic (neural tube defects)

From QM: Anaemia, confusion, gastric irritation, haemorrhage, hyponatraemia, tremor, weight gain

Question 22

Side effects of carbamazepine?

Answer 22

From Z2F - agranulocytosis, aplastic anaemia and induces P450

From lec and BNF:
P450 enzyme inducer
dizziness and ataxia
drowsiness
leucopenia and agranulocytosis
syndrome of inappropriate ADH secretion
visual disturbances (especially diplopia

Question 23

What blood monitoring needs to be done for Sodium valproate?

Answer 23

Vit D levels regularly
FBC - thrombocytopenia
LFTs - liver failure
Pregnancy

Question 24

What blood monitoring needs to be done for carbamazepine?

Answer 24

Blood counts
Plasma conc
Renal and hepatic monitoring

Question 25

Side effects of Lamotrigine?

Answer 25

Stevens johnson syndrome or toxic epidermal necrolysis (often 1st 8 weeks) warn to see dr if rash or flu symptoms

diplopia
blurred vision
photosensitivity
tremor
agitation
aplastic crisis

Quesmed: blurred vision, arthralgia, ataxia, diarrhoea, dizziness, headache, insomnia, rash, tremor.

Question 26

What is status epilepticus?

Answer 26

When > 5mins continuous or 2+ seizures without full recovery within 30 mins

Question 27

How do you manage status epilepticus?

Answer 27

A-E assessment–> IV lorazepam 4mg–> after 10- 15mins if seizure has not stopped IV lorazepam 4mg–> once established status (this means ongoing) Phenytoin infusion 20mg/kg- max rate 50mg/min–> call ITU–> rapid sequence induction- thiopental etc.

Question 28

What can you give in status epilepticus if there is no access?

Answer 28

IM midazolam 10mg
PR diazepam 10mg

Question 29

What are febrile convulsions?

Answer 29

Children between 6mnths- 5years
Usually occur early in viral infection as temp rises rapidly
Brief and generalised tonic/tonic- clonic

Question 30

What are alcohol withdrawal seizures?

Answer 30

Pts with hx of alcohol excess if suddenly stop drinking
Peak incidence is around 36 hours following cessation of drinking
Pts give benzodiazpines following cessation to reduce the risk

Question 31

Psycho-genic non-epileptic seizures

Answer 31

pt presents with epileptic type seizures but does not have the characteristic electrical discharge
Pts may have hx of mental health problems or a personality disorder

Question 32

Lactate levels in pt who has had generalised tonic clonic seizure?

How doe this differ to syncopal pt?

Answer 32

T-C seizure: Raised lactate ! (this is due to local muscle hypoxia during seizure)

Syncopal: normal lactate

Question 33

What is idiopathic generalised epilepsy?

Answer 33

A group of epileptic disorders that are believed to have strong underlying genetic basis and strong FHx

Pts are otherwise normal with no structural brain abnormalities

Starts early childhood - adolescence

Seizure types include absence, myoclonus and primary generalised T-C

Question 34

Why are vitamin D levels monitored in patients taking sodium valproate?

Answer 34

Sodium valproate induces metabolism of vitamin D so need to routinely measure levels

Question 35

Management of atonic seizures?

Answer 35

Tonic or atonic seizures:

• males: sodium valproate
• females: lamotrigine