seizures and blackouts 2 Flashcards
What are essential steps in taking a history from epilepsy possibility
Pt and witness history
Ask about before during ad after event
Questions to ask when investigating a possible seizure
'tell me what happened when...' beginning..: “Tell me what you were doing and feeling like before the attack” What was the first thing that happened? What happened next…and next…? Did you lose consciousness? How did you feel as you came to? Is this the first time this has happened?
Questions to ask before the attack
Dizzy, light headed, hot/cold, nausea
Was vision affected ?
(eg. Fading-syncope ; Coloured lights occipital seizure; Zig-zags migraine
Was hearing affected (whooshing..)
Tingling
Jerking / spasms
Déjà vu, rising sensation, olfactory/gustatory sensations
questions to ask during the attack
Did you have any awareness? Were you frightened or upset? Did you feel unreal? Could you hear what was going on around you? Could you control your movements?
In tonic clonic pt will not have awareness, but in dissociative seizure they may retain what was going on
Questions to ask after the attack
What did you feel like as you come round? Were your muscles sore? Headache / Back ache? Incontinence? Tongue biting (and where) Confusion Memory Emotions
what to ask the witness
Before: What was the patient doing? During: What happened at the very beginning? Describe Eyes Face Limbs Breathing Sound (e.g. vocalization, breathing) Timing and evolution How did it end? After: Post-ictal features: tongue biting, incontinence, noisy raspy breathing Recovery: speed, confusion, amnesia
Non-epileptic attack patterns
Panic / hyperventilation
Dissociation
Prolonged motionlessness
Prolonged attack atypical features
How to assess if syncope is benign or sinister
History (vasovagal or cardiac)
Heart exam and postural blood pressure
ECG
What to do if syncope points to benign or sinister causes
Benign- discharge with lifestyle advice
Sinister- cardiology review
How to assess a new case of epilepsy
IS it benign or focal? if focal more likely to be sinister
- Neurological exam
- Full recovery- if long could be sinister
Do an ECG
Bloods: FBC, Na, Ca, Glu, pH, lactate
What to do if it is a benign cause of epilepsy
What if its sinister
-Discarheg with safety advice and neurological follow up
Sinister: admit, scan, treat
What should you always consider with new cases of epilepsy
Infection
Lesion
Toxic/alcohol
MEtabolic
What infections can give rise to seizures
Signs?
INvestigations?
Encephalitis
Abscess
Meningitis
Signs: fever, headache, rash
Investigations: Urgent CT+ lumbar puncture
What lesions can give rise to seizures
Signs?
Investigations?
Stroke (older patients)
Tumour (younger patients)
Trauma (younger patients)
Signs: slow recovery
investigations: urgent CT then MRI
Initial treatment of new repeated seizures
ABC
IV lorazepam 2-4mg
Repeat at 10 mins + load levetiracetam or valproate 30mg/kg
Call for back-up
What is the first line for most seizures
- Common side effects?
- Common interaction?
Lamotrigine
- Rash
- COCP
What is a good alternative to lamotrigine especially if rapid control needed
- Common side effect?
- interactions
Levetiracetam
Mood disturbance
No interactions
What is the most effective drug for generalised epilepsy
Valproate
what is second line for focal epilepsy
side effects
Interactions
Carbamazepine
Skin rash
MAny
What is phenytoin used for
What drugs have replaced it in emergencies
Common side effects
Focal epilepsy
Levetiracetam and valproate
Side effects: sedation, ataxia, many interactions
What is clobazam used for
It isa benzodiazepine
Used for clusters of seizures
What is used for patient prone to prolonged seizures to prevent hospitalisation
Buccal midazolam
Rules of driving
People with an episode of loss of unconscious must stop driving awaiting assessment
Diagnosis of a single epileptic seizure will result in at least 6 months off driving
Diagnosis of epilepsy (2 seizures over 5 years) will result in a one year ban
