Epilepsy Long Flashcards
Key questions to ask in children with Seizures?
- Prodrome/precipitating factors
- Aura
- Initial cry/scream
- Initial localizing signs
- Manifestations of seizures
- Duration
- Frequency
- Time of occurrence
- Date/time last seizure
- Postictal events
- Neurological dysfunction
- PHx
- FHx
- Crisis plan
What to consider in child with intractable seizures?
1) Right diagnosis? : Undiagnosed metabolic, neurodegenerative, organic pathology, neurocutaneous disorder, Pseudoseizures/ behavioural manifestation
2) Adolescents: Poor adherence? – depression? (esp in adolescents), Substance abuse/illicit drugs?, Pregnancy???
3) Drug issue: Drug interaction? CYP450 decreases drug effectiveness (CARBOS – CBZ, alcohol, rifampicin, barbiturates (PHB, PHT), oestrogen, St John’s Wort), Drug side effect? e.g. hyponatremia from CBZ, Drug correct? E.g. CBZ worsens GTCS
4) Precipitant: Unwitnessed recent head injury/fall?, Subclinical infection?, Environmental stimulus e.g. television
5) Investigations: If adherence issue – consider drug level; Electrolytes, Repeat imaging (MRI), EEG (+/- video EEG if unclear), Revisit past investigation incl metabolic studies
6) Management: Meds – consider prev treatment; what max dose; why stopped?, Ketogenic diet, Vagal nerve stimulator, Surgery
Side effect of Carbamazepine?
rash, leukopenia, hyponatraemia
Side effects of Valproate?
weight gain, hair loss, pancreatitis, hepatic failure
Side Effect of Clonazepam?
Increased secretions, coordination issues, memory issues, muscle pain, increased urination
Side Effects of Phenobarbitone?
Rash, drowsiness
Side Effects of Phenytoin?
rash, serum sickness, hirsutism, gum hypertrophy, osteoporosis
Side Effects of Lamotrigine?
rash, SJS, severe hypersensitivity
Side Effects of Vigabatrin?
weight gain, retinopathy, psychosis
Side Effects of Topiramate?
nephrolithiasis, weight loss, acidosis, glaucoma, hypohydrosis/hyperthermia
Side Effects of Oxcarbazepine?
hyponatraemia
Side effects of Levetiracetam?
Blocked nose, itchy throat, irritability, headaches, nausea, confusion/abnormal behaviour, renal issues (Rare)
Epilepsy Mx after first diagnosis?
1) Discuss with parents re: anti-epileptic medication
- Why treat? Risk of injury - e.g. absence seizure when crossing road, mechanical injury from convulsion, Learning impairment (esp BFEC), Improvement of self-esteem, Long Term brain injury – concern if fit for >30-60 mins in a normal brain OR fit for >15 minutes in abnormal brain
- Probably duration of treatment usually 2 years
- Warn of side effects: Na channel blockers – drowsiness, headaches, vomiting, diplopia; GABA meds – behavioural, mood instability, irritability, aggression, ataxia, Drug specific – rash, vision, weight, rickets..etc
2) Safety issues: Have showers, avoid baths, No swimming alone, climbing ladders, skateboarding/rollerblading on busy roads, No diving/surfing, tandem skydive OK, Provision of helmets when riding on less busy roads, Avoid overprotection – allow participation in normal sports
3) Safety issues for Adolescents: Driving – usually need to be seizure-free for 2 years, Contraception and pregnancy, folate for women
4) Avoid known precipitants: e.g. sleep deprivation, avoid sitting close to television & changing channels
5) Outline contingency plan/ensure have plan:
- Position in left lateral position, airway protection, remove dangerous objects
- Look at clock & start timing, call ambulance at 5 mins, emergency PR diazepam, IN midazolam if available
- Inform child care and other carers – have written plan & emergency medication
- Do they have ambulance cover?
- Do parents need CPR training?
6) Long term monitoring of seizure response and drug side effects
Predictors of seizure recurrence once medications are stopped?
o Epilepsy syndrome itself
o Focal seizures (excluding benign rolandic epilepsy)
o Abnormal neurological signs
o Mixed type of seizures
o Seizures that were originally difficult to control
