Syncope/Seizures Flashcards
What are the types of reflex syncopes?
Vasovagal (fainting):
Triggered by emotion, pain or stress
Preceded by feeling light headed, pale, sweaty, blurred vision
LoC lasts 2 mins, no post-ictal state
Situational:
Triggered by cough or micturition
Carotid sinus:
Triggered by turning head or shaving
What are causes for postural hypotension?
Primary autonomic failure:
Parkinsons
Lewy body dementia
Secondary autonomic failure:
Diabetes
Uraemia
amyloidosis
Drug-induced:
Diuretics
Vasodilators
Alcohol
Volume depletion:
Haemorrhage
Diarrhoea
What are causes of cardiac syncope?
Arrhythmias
Structural abnormalities
PE
What investigations can be carried out in seizures?
Neurological exam
General observations, O2, blood sugars
Routine bloods: FBCs, U&Es (acute metabolic disturbances e.g. hyponatraemia, hypocalcaemia), LFTs
CT/MRI scan – to exclude acute pathology
ECG – seizure could be secondary to arrythmia, due to secondary cerebral hypoxia
EEG - to identify different forms of seizures
What are the features of generalised tonic-clonic seizures (GTCS)?
Involves both sides of the brain
Symptoms: Immediate LoC Tonic phase (muscle tensing), then clonic phase (muscle jerking) after Tongue biting Incontinence Groaning Irregular breathing
Post-ictal period: Drowsy Confused Irritable Depressed
What is the treatment for GTCS?
1st line = sodium valproate
2nd line = lamotrigine or carbamazepine
What are the features of focal (partial) seizures?
Starts in a specific area, on one side of the brain
Symptoms: Hallucinations Memory flashbacks Déjà vu Doing strange things on autopilot
What are the different types of focal seizures?
Focal aware seizures (simple partial):
Only affects a lobe or small structure in brain
Patient remains fully aware
Can develop into secondary GTCS
Focal unaware seizures (complex partial):
Affects unilateral cerebral hemisphere
Patient awareness and responsiveness is impaired during event but may not lose consciousness completely
What is the treatment for focal seizures?
1st line = lamotrigine or carbamazepine
2nd line = sodium valproate or levetiracetam
What are the features of temporal lobe seizure?
Most common type of focal seizure
Symptoms: Déjà vu Olfactory and auditory hallucinations Feeling of rising epigastric sensation Derealisation or depersonalisation Automatism Lip smacking Mumbling
What are the feature of absence seizures?
Typically being in 3-10 year olds
More common in girls
Begins on both sides of brain, therefore it is a type of generalised seizure
Symptoms:
Lasting a few seconds and quick recovery
Brief lapses in muscle tone
Patient ‘blanks out’ or ‘stares into space’
May indicate Lennox-Gastaut syndrome
What is the treatment for absence seizures?
1st line = sodium valproate
2nd line = lamotrigine
What are the features of myoclonic seizures?
Typically occurs in children with Juvenile myoclonic epilepsy
Symptoms:
Sudden brief muscle contraction, like a ‘jump’
Remains awake
What is the treatment for myoclonic seizures?
1st line = sodium valproate
2nd line = lamotrigine, levetiracetam or topiramate
What are the features of infantile spasms?
In infants age 6 months Rare Flexion of head, trunk, limbs and extension of arms Last 1-2 secs Repeated up to 50 times Progressive mental handicap
What is the treatment for infantile spasms?
Prednisolone
Vigabatrin
What are febrile convulsions?
Typically in 6mnth - 5 year olds
Usually occur early in viral infection
Seizures typically brief and GTCS in nature
Some children who had febrile convulsions go on to have epilepsy later on in life
The epilepsy that develops later in life typically takes the form of seizures originating in 1 of the temporal lobes
These are associated with atrophy and scarring (gliosis) visible in the temporal region on MRI = mesial temporal sclerosis (MTS)
What are the features of psychogenic non-epileptic seizures?
Present with epileptic-like seizures but do not have characteristic electrical changes
Symptoms: Pelvic thrusting Crying after seizure Doesn't occur when alone Gradual onset More common in females
What would indicate a true seizure rather than a psychogenic non-epileptic seizure?
Tongue biting
Raised prolactin
What is the definition of status epilepticus?
Defined as seizures lasting more than 5 minutes or 2 or more seizures within 5 minutes apart
What is the management for status epilepticus?
Take ABCDE approach:
Secure airway
Give high conc. O2
Assess cardiac and respiratory function
Check blood glucose levels
Gain IV access so insert a cannula
1st line: IV lorazepam 4mg, or buccal midazolam 10mg, repeated after 10 minutes if the seizure continues
If seizure persist >10mins: IV phenytoin (15-18mg/kg) or IV sodium valproate (10mg/kg) or IV levetiracetam (30mg/kg) or IV phenobarbital (only in ITU when patient intubated)
If seizure persists >30 mins: general anaesthetic
What medications are P450 enzyme INDUCERS that shorten the effects of other drugs?
Carbamazepine Phenytoin Phenoborbital Rifampicin Chronic alcohol abuse
What medications are P450 enzyme INHIBITORS that increase the concentration of other drugs?
Sodium valproate Metronidazole Amiodarone Cimetidine Acute alcohol intake
What neurotoxic side effects commonly occur in all anticonvulsants?
Dizziness Drowsiness Diplopia Ataxia Incoordination Cognitive slowing
