What are the different causes of blackouts?
(narcolepsy, movement disorder, migraine)
What is the best way to differentiate between different reasons for blackouts?
Detailed history from patients
Detailed history from witness
What are relevant questions to ask the patient after a black out?
What were they doing at the time?
What, if any, warning feelings did they get?
What were they doing the night before?
Have they had anything similar in the past?
How did they feel afterwards?
Any injury, tongue biting or incontinence?
What are important pieces of information to ascertain from a witness of a blackout?
Observations before and after an attack - level of responsiveness, motor phenomena, pulse, colour, breathing, vocalisation, behaviour following attacks
What other relevant information exists to ask a patient after a blackout?
past medical history including head injury, birth trauma and febrile convulsions
past psychiatric history
alcohol and drug use
What is the most common cause of fainting?
What is the prodrome of syncope? Prodrome is an early symptoms indicating the onset of a disease or illness
What are triggers for vasovagal syncope?
Standing up quickly
Watching/experiencing medical procedures
Micturition - urinating, more common in men
Describe the differences between syncope and seizure with regard to posture, skin colour, onset, injury rate, incontinence rate, recovery rate and precipitants?
Syncope - upright posture, pallor common, gradual onset, injury rare, rapid recovery, precipitants are common
Seizure - any posture, pallor is uncommon, sudden onset, injury is common, slow recovery, precipitants are rare
What are the causes of hypoxic seizures?
When individuals are kept upright in a faint, occurs, can occur in aircraft, at the dentist, when well-meaning passersby help people to their feet....
The patient may have a succession of collapses, seizure - like activity may occur
When do concussive seizures happen?
After any blow to the head
Give an example of a cardiac arrhythmia the can cause a seizure
Long QT syndrome
Is a seizure likely or unlikely to happen during sport?
When should you seriously consider that a seizure is as a result of cardiac arrhythmia?
When there is a family history of sudden death, or when the collapse occurs with exercise. Seizures can also cause cardiac arrhythmias
What demographic is more likely to have non-epileptic attacks?
More likely to happen in women
What is the difference between non-epileptic attacks versus epileptic attacks?
Non-epileptic attacks - alternating movement, side to side head movement may look bizarre, prolonged, can be frequent. May superficially resemble a tonic-clonic seizure
Seizures - pattern of jerking movements, usually bilateral
What are investigations for possible first seizures?
Blood sugar (eliminates the seizure as a result of severe hypoglycaemia)
Consideration of alcohol and drugs
What are the functional consequences of having a first seizure?
Potential employment issues
Some leisure activities may now be seriously dangerous (paragliding, rock climbing)
What are driving regulations after a patients first seizure?
May drive after 6 months if their investigations are normal and they have had no further events
May drive an HGV or PSV (public service vehicle) after 5 years if their investigations are normal, they have no further events and they are not on anti-epileptic medication
How is the diagnosis of epilepsy often made?
Normally diagnosed after a second unprovoked attack but sometimes on taking the history after a first seizure, it is clear that they have undiagnosed epilepsy.
What are features suggestive of epilepsy?
History of myoclonic jerks, especially first thing in the morning, absences or feeling strange with flickering lights – in keeping with a primary generalised epilepsy
History of “deja vu”, rising sensation from abdomen, episodes where look blank with lip-smacking, fiddling with clothes – suggest a focal onset epilepsy
What is an epileptic seizure?
An intermittant stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds, is believed to result from abnormal neuronal discharges
Epilepsy is a condition in which seizures recur, usually spontaneously
What demographic is associated with higher prevalence of epilepsy?
Learning disability - 22% of patients with LD have epilepsy
What are the two main types of seizure as described by the ILAE?
Generalised seizures and focal seizures
What are the different types of generalised seizures?
Myoclonic seizures - jerky and clumsy in the morning
Tonic seizures - stiffenening movement
Atonic seizures - rapid collapse to the floor - facial injuries are common
Absence seizures - children with very frequent attacks, last a very short time, kids grow out of absence seizures by 12 years old usually
What do the words tonic and clonic mean with reference to a tonic clonic seizure?
Tonic means stiffening, and clonic means rhythmical jerking.
What are the stages of a tonic clonic seizure?
First is the tonic stage - The muscles stiffen and the patient falls to the floor
Then clonic stage - The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees.
After a few minutes, the jerking slows and stops.
What are features of a focal seizure?
Characterised according to aura, motor features, autonomic features and degree of awareness or responsiveness
May evolve into a generalised convulsive seizure
Autonomic features - heart changes rate, sweating
What are the differences between primary generalised and focal/partial epilepsies?
In terms of warning, age of population likely to be affected, Findings on EEG
Primary generalised - no warning, usually diagnosed under the age of 25, generalised abnormality on EEG
Focal - may get an aura, any age - cause can be any focal brain abnormality, focal abnormality on EEG (MRI may show the cause)
What is the difference between a simple partial seizure and a complex partial seizure?
Partial seizure is another way of describing a focal seizure
Simple partial seizure - no loss of awareness
Complex partial seizure - any disturbance in conscious level
Describe the seizures that happen in patients with learning difficulty
Unclassified seizures which are unique to them, repetitive movements and apparently fairly stereotyped events which are behavioural but which can be difficult to diagnose
What are the relevant investigations for patients who have seizures?
EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
Video-telemetry if uncertainty about diagnosis
What is the first line treatment for generalised epilepsies?
Sodium valproate - although carries large risk of foetal abnormality - delayed language development
What is the first line treament for partial and secondary generalised seizures?
What is the treatment for absence seizures?
What is the first and second line treatment for status epipepticus?
Lorazepam, midazolam: First line
Valproate or phenytoin: Second line
What is second line treatment for generalised epilepsy?
What is second line treatment for partial seizures?
What are the side effects of sodium valproate?
Tremor, weight gain, ataxia, nausea, drowsiness, transient hair loss, pancreatitis, hepatitis
What are the side effects of carbamazepine?
- ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash
What are the side effects of lamotrigine?
What are the side effects of levetiracetam?
What are the side effects of topiramate?
weight loss, word-finding difficulties, tingling hands and feet
What are the regulations for people wanting to use a group 1 license?
Patients can hold a Group 1 licence once they have been seizure free for a year or have only had seizures arising from sleep for a year. If they have ever had a day time seizure but then the pattern becomes noctural, this must be established for three years before they can drive
Daytime seizure at any point and then sleeping seizures – have to have that pattern for three years
Have to have a sleep seizure pattern of at least a year before you are allowed to drive
What is status epilepticus?
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
Who is at risk of status epilepticus?
Usually occurs in patients with no previous history of epilepsy (stroke, tumour or alcohol)
What is the mortality rate for status epilepticus?
What is the the treatment for tonic clonic status epilepticus?
Midazolam - buccal or nasal
Lorazepam - bolus
Diazepam - iv or rectal
What is second and third line therapy for tonic clonic status epilepticus
Second line - Phenytoin
Third line - Anaesthesia, usually with propofol or thiopentone
When death occurs after a TCSE, what is the death most likely to be secondary to?
Who is mortality most common in for TCSE?
Very young and very old
(29% of those less than 1 year)
90% of deaths are a result of underlying cause