Seizures, Epilepsy, Syncope Flashcards
Difference between seizures and epilepsy
Seizures - Sudden uncontrollable electrical brain activity that leads to changes in sensation, movement, consciousness, behaviour
Epilepsy - 2+ unprovoked seizures in under 24hrs
Definition of syncope
Cardiovascular reasons for LOC
Syncope - a result of brain hypoperfusion, from reduced CO
Structural heart conditions
-aortic stenosis, HOCM, dissection
Arrythmias
Vasovagal
Cough/straining
-increased intrathoracic pressure decreases cardiac return and CO
Volume depletion
-diuretics, HTN drugs, autonomic neuropathy
Main features of syncope
-situation
-before
-during
-after
Situation
-positional changes
-situational (standing too long, dehydration, stress)
Before - cardiac symptoms, SNS activation from hypoperfusion
-pale, sweaty
-lightheaded
-altered vision
During
-U1 min
-pale, sweaty, slow weak pulse
-some myoclonic jerks after LOC
After
-rapid recovery
-no confusion
Definition of seizures
Causes of seizures
Seizures - abnormal neuronal activity => decreased inhibitory activity
Epilepsy
Brain injury, infection, tumour
-stroke, MS, PD, dementia
PNES
Drug abuse, alcohol withdrawal
Main features of seizures
-triggers
-before
-during
-after
Triggers
-none
-stress, tired
-drugs, alcohol/withdrawal
-periods
-flashing lights
Before - neuro symptoms from decreased inhibitory activity
-altered sensation, movement, feelings
-dejavu, jamaisvu
-sensory aura (visual/olfactory)
During
-s-mins
-LOC possible
-bite tongue
-abnormal posture
-incontinence
-eyes open in epilepsy, closed in PNES
After
-amnesia
-post ictal phase
Investigations for LOC/seizures
Rule out infection (sepsis, meningitis, enceph), low glucose, cardiac causes, evidence of heavy alcohol use
HO
Examination - cranial, eyes, limbs
Bedside - urinedip, CBG, ECG
Bloods - FBC, LFT, RFT, U&E, BM, cultures
Imaging - echo, CT, MRI
Special - EEG, LP
Management for seizures
-non medical
-in the moment
Non medical
-identify and avoid triggers
-report to the DVLA (cannot drive for 6 months post-seizure, 12months epilepsy free)
Acute - normally end spontaneously
-SAFETY
-note start and end time of seizures, auras, post ictal phases
Rescue medication - BZ
SE => LAS, more BZ, AED infusion, GA
Medication given for epilepsy after the 2nd seizure
Epilepsy
-diagnosis and investigations
-management
1st seizure => EEG and MRI
-assess for other differentials
Start AED after 2nd seizure unless
-neuro deficit
-structural abnormality
-EEG unequivocal activity
-patient/family considers risk of future seizure unacceptable
Classification of seizures
- Start location
- Awareness
- Other features
Focal seizures characteristics
-1st line management
Start on 1 side
Awareness varies
Motor/non-motor
Aura
Lamotrigine/levetiracetam
Seizures characteristics
-Generalised
-Myoclonic
-Tonic/Atonic
-Absence
1st line management
Involve both sides of brain at onset
Full LOC
Generalised motor
Men - Valproate
Women - Lamotrigine/leviteracetam
-myoclonic - levetiracetam
-tonic/atonic - lamotrigine
Non-motor - absence
1st line - ethosuximide
2nd line - same as motor
Unknown onset
Focal to bilateral seizure
-characteristics
Unknown - reserved from when the origin is unknown
Focal => bilateral - starts focal but becomes bilateral
Examples of paediatric epilepsy
Infantile spasms - poor prognosis, 2ndary to neuro abnormality
Lennox Gastaut - may be extension of infantile spasms
Rolandic - parasthesia on waking
Juvenile myoclonic - sleep deprivation
Management of patients who drive
Report seizures to DVLA
Isolated seizure free for 6 months
Established epilepsy - 12 months seizure free
Management of patients on other medications
AEDs affect the P450 system => alters metabolism of other meds (warfarin)
Contraception and AEDs affect each other
Management of patients wishing to get pregnant
Valproate is teratogenic => NDDs
Seek advice from a neurologist before pregnancy
Breastfeeding is ok unless using barbiturates
Localising focal seizures
-temporal
-frontal
-parietal
-occipital
Temporal (HEAD)
-hallucinations
-epigastric rising, emotional
-automatisms
-dejavu
Frontal - motor
-weakness, posturing
Parietal - paraesthesia
Occipital - visual
-floaters, flashes
Status epilepticus
-management
Seizure lasting 5mins+
Get IV access, request urgent bloods to look for underlying cause
Within 5mins - BZ
No response within 10mins - BZ+AED
No response within 45mins - GA
Febrile seizures
-associations
-presentation
-types
-management
6months-5years
Occur when temperature increases rapidly
TC U5mins
-LAS if 5mins+
Simple - U15mins
-generalised
-no recurrence within 24hrs
-complete recovery in 1hr
Complex - 15-30mins
-focal
-repeat within 24hrs
SE - 30mins+
If recurrent => use rectal diazepam/buccal midazolam
Prognosis and link between febrile seizures and epilepsy
Recurrence of febrile seizures increases if
-onset U18months
-39C+
-short fever duration
-FHx
Link to epilepsy generally v low unless
-FHx
Stopping AEDs
Considered if seizure free for 2years+
AED stopped over 2-3months
Syncope
-investigations
-management
CV exam
Lying, standing BP
Postural drop if
-symptomatic fall in SBP 20+ OR DSP 10+ OR SBP U90
ECG
Difference between myoclonic and tonic clonic seizures
Myoclonic - rapid contractions and relaxations
-no LOC, incontinence, tongue biting or postictal phase
-rapid contractions => fall to the floor
-short duration
Tonic clonic - tonic phase => clonic phase
-LOC, incontinence, tongue biting, postictal phase
-initial stiffening => fall to the floor => clonus
