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PPNP 3 > Seizures & Anti-epiletics CA > Flashcards

Seizures & Anti-epiletics CA Flashcards

1
Q

What is a seizure?

A

A paroxysmal event due to an abnormal hyper-synchronous discharge from a mass of CNS neurons.

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2
Q

What is epilepsy?

A

A disorder of the brain characterised by repeated seizures.

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3
Q

What indicates a lower risk of recurrence of seizure?

A
  1. Single seizure
  2. Normal EEG
  3. Normal brain scan
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4
Q

What indicates a higher risk of recurrence of seizure?

A
  1. Previous (undiagnosed) seizures
  2. Epileptiform (abnormal) EEG
  3. Abnormal brain scan
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5
Q

Causes of epilepsy

A
  1. congenital/hereditary
  2. brain injury, scarring or tumour
  3. infections: meningitis or encephalitis
  4. blood glucose alterations: chronic hypoglycemia
  5. metabolic disorders: adrenal insufficiency leading to hyponatremia
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6
Q

Investigations to be ordered for epilepsy

A
  1. Blood tests (Liver function, blood chemistry– electrolytes, glucose, calcium & magnesium)
  2. EEG
  3. Brain scan (CT/MRI)
    (to determine risk of recurrent seizures)
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7
Q

Epilepsy/seizure classification

A
  1. Generalised seizure: grand mal/tonic, petit mal/absence, myoclonic, atonic
  2. Partial seizure: simple, complex
  3. Status epilepticus: severe form, medical emergency
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8
Q

Rationale for the use of anti-epileptics

A
  1. Decrease membrane excitability by altering Na+ and Ca2+ conductance during action potentials.
  2. Enhance effects of inhibitory GABA neurotransmitters.
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9
Q

What are some common drugs used in the treatment of seizures and epilepsy?

A

Phenytoin, Carbamazepine, Valproate, Diazepam

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10
Q

What is the MOA of phenytoin?

A

Reduces excitatory sodium signals by acting as a blockade of voltage-dependent Na+ channels

Note: Narrow therapeutic range (<40 no effect, >100 becomes toxic)

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11
Q

Which anti-epileptic drug should be given first-line for newly diagnosed partial and generalised tonic clonic seizures?

A
  1. Carbamazepine
  2. Phenytoin
  3. Sodium valproate
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12
Q

Which anti-epileptic drug should be given first-line for absence seizure?

A

ONLY sodium valproate

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13
Q

Important contraindication of Phenytoin

A

Teratogenic: leads to birth defects in fetus, contraindicated in pregnant women!

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14
Q

What is the MOA of carbamazepine

A

Similar to phenytoin:

Reduces excitatory sodium signals by acting as a blockade of voltage-dependent Na+ channels

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15
Q

Important considerations on the use of Carbamazepine

A
  1. Drug interactions: Hepatic enzyme (CYP450) inducer, lead to reduced efficacy of other drugs metabolised by these enzymes, hence dosage of other drugs needs to be increased
  2. Side effects: Aplastic anemia due to inability of bone marrow to produce all kinds of blood cells
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16
Q

What is the MOA of valproate?

A
  1. Acts as a blockade of voltage-dependent Na+ and Ca2+ channels hence decrease excitatory tone
  2. Inhibits GABA transaminase (which breaks down GABA), hence increase GABA, increase inhibitory tone
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17
Q

What kinds of seizures is valproate used for?

A

All types of seizures, including absence seizure

18
Q

Important considerations on the use of Valproate

A
  1. Valproate binds strongly to plasma proteins and displaces other anti-epileptics, causing them to be unbound and active, increasing the effects of other drugs—hence need to readjust dose of other anti-epileptic medications
19
Q

What are some dose-related adverse effects of anti-epileptics in general?

A
  1. Drowsiness, confusion
  2. Nystagmus (involuntary, rapid, and repetitive movements of the eyes, can be horizontal, vertical, or rotational)
  3. Ataxia (poor muscle control)
  4. Slurred speech
  5. Nausea
  6. Unusual behaviour
  7. Mental changes
  8. Coma
20
Q

What are some non-dose related effects of anti-epileptics in general? (may arise even if very low dose given)

A
  1. Hirsutism (excessive hair growth)
  2. Acne
  3. Gingival hyperplasia (gums overgrowth)
  4. Folate deficiency
  5. Osteomalacia (bone softening)
  6. Hypersensitivity reactions (including SJS)
21
Q

MOA of benzodiazepines. How are benzodiazepines used in the context of epilepsy?

A

MOA: increase effect of inhibitory GABA neurotransmitters, potentiates influx of Cl- ions, lead to hyperpolarization, inhibit firing of neurons

Used as a sedative for anti-anxiety effects

22
Q

Which types of benzodiazepines are used a anti-epileptics? SA or LA?

A

Short Acting (SA) benzodiazepines are not usually used for anti-epileptic purposes (NO Midazolam/Triazolam)

Epilepsy is a chronic illness. More frequent doses = more adverse effects.

23
Q

What benzodiazepines are used for anti-epileptics purposes?

A

Intermediate acting: Clonazepam, Lorazepam

Long acting: Diazepam

Note: Used for refractory seizures (which are not effectively controlled by first-line medications (carbamazepine, valproate, phenytoin), also used during status epilepticus

24
Q

When are anti-epileptic drug levels tested?

A
  1. Assessment of compliance to drug treatment for pts with refractory epilepsy
  2. Assessment of symptoms due to possible antiepileptic drug toxicity
  3. Titration of phenytoin dose (due to narrow therapeutic window)

Note: Routine checking not required and not cost effective

25
Q

Which antiepileptic drug should be chosen initially

A
  • depends on which the physician is the most familiar with
  • begin with monotherapy:
    Carbamazepine, phenytoin (note teratogenic) and sodium valproate can be considered first line treatments but absence seizure can only use sodium valproate
  • Use the lowest dose which control seizures
  • Depends on pt financial situation
26
Q

What increases risk for breakthrough seizures?

A
  • Non-compliance to antiepileptic meds or drugs
  • Interactions with antiepileptic meds lowering blood levels of antiepileptic drugs
  • Alcohol abuse

-Sleep deprivation

-Concurrent illness

27
Q

Symptoms of generalised tonic-clonic seizure

A

Unconsciousness, followed by body stiffening (TONIC phase), violent jerking (CLONIC), dives into a deep sleep after (POST-ICTAL phase)

28
Q

Symptoms of absence seizure

A

Brief LOC, interrupts an activity and stares blankly

May occur several times a day

29
Q

Symptoms of myoclonic seizure

A

Sporadic/irregular jerks, BOTH sides of body jerking movements, clustered, no LOC

Jerks are described as electrical shocks

30
Q

Symptoms of clonic seizure

A

Rhythmic jerks of BOTH sides of the body

31
Q

Symptoms of tonic seizures

A

Muscle stiffness, rigidity

32
Q

Symptoms of atonic seizures

A

Loss of muscle tone in four limbs

33
Q

What are partial seizures?

A

produced by a small area of the brain

Caused by any type of focal injury that leaves scar tangles
Usually caused by (identified by medical history/MRI):
- Trauma
- Stroke
- Meningitis

34
Q

Symptoms of a simple, partial seizure

a. Simple motor
b. Simple sensory
c. Simple psychological

A

a. Jerking. Muscle rigidity, spasms, head-turning

b. Usual sensations affecting either the vision, hearing, smell taste, or touch

c. Memory or emotional disturbances

35
Q

Symptoms of a complex, partial seizure

A

Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements

36
Q

Symptoms of a partial seizure with secondary generalisation

A

Symptoms that are initially associated with a preservation of consciousness that then evolves into LOC and convulsions

37
Q

What are the phases of a seizure?

A

Before a seizure: Prodromal

  1. Early ictal (aura)
  2. Ictal (middle)
  3. Post-ictal (ending)
38
Q

What are some common symptoms experienced during the prodromal and early-ictal (aura) phase?

A

Prodromal:
- Mood changes
- Anxiety
- Feeling lightheaded
- Difficulty sleeping
- Difficulty staying focused
- Behaviour changes.

Early-ictal (aura):
-Bitter, acidic taste
- Déja Vu
- Dizziness
- Flickering vision
- Hallucinations
- Head, arm, or leg pain
- Nausea/stomachache
- Numbness
- Out-of-body sensation
- Ringing or buzzing sounds
- Strange, offensive smells
- Strong feelings of joy, sadness, fear, or anger
- Subtle arm or leg twitching
- Tingling
- Vision loss or blurring

39
Q

What are some common symptoms experienced during the ictal phase?

A

Arm or leg stiffening
Chewing or lip-smacking
Confusion
Difficulty breathing
Distractedness
Drooling
Eye or head twitching movement in one direction
Hearing loss
Inability to move or speak
Loss of bladder and/or bowel control
Memory lapses
Numbness
Pale/flushed skin
Pupil dilation
Racing heart
Sense of detachment
Strange sounds
Sweating
Tremors
Twitching
Unusual physical activity such as dressing/undressing
Vision loss, blurring, flashing vision
Walking/running

40
Q

What are some common symptoms experienced during the post ictal phase?

A

Arm or leg weakness
Body soreness
Confusion
Difficulty finding names or words
Drowsiness
Feelings of fear, embarrassment, or sadness
General malaise
Headaches/migraines
Hypertension
Memory loss
Nausea
Thirst

PPNP 3 (12 decks)

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