Epilepsy & management of convulsions / anticonvulsants

Question 1

what is a seizure

Answer 1

Seizure is a sudden change in behaviour caused by electrical hyper synchronization of neuronal networks in the cerebral cortex

Question 2

difference between provoked and unprovoked seizure

Answer 2

unprovoked is unknown

provoked is drug or alcohol, stroke, encephalitis and acute head injury

Question 3

encephalitis
what is it
symptoms

Answer 3

Encephalitis is inflammation of the active tissues of the brain caused by an infection or an autoimmune response. The inflammation causes the brain to swell, which can lead to headache, stiff neck, sensitivity to light, mental confusion and seizures.
vomiting

Question 4

what is epilepsy

Answer 4

Epilepsy is more than 2 unprovoked seizures occurring within a 24 hour apart

1 unprovoked seizure and a problability of further seizure similar to general recurrence risk after 2 unprovoked ( eg more than 60%) occurring over the next 10 years
Diagnosis of an epilepsy syndrome

Question 5

two main types of seizures

Answer 5

focal

generalsied

Question 6

what is a focal seizure

very small area

Answer 6

origin in one hemisphere

Question 7

first line for focal seizures

Answer 7

carbamazepine

Binds to sodium channels increases their refractory period

Question 8

what is a generalised seizure

bigger

Answer 8

both hemipspheres - bilateral discharges involve subcortical structures
impairment of conciseness

examples include , absence, myoclonic, atonic( lose muscle power) , clonic, tonic( stiff) and tonic/clonic

Question 9

first line for generalised seizures

Answer 9

sodium valproate

Question 10

• Case 1 Mr Myshkin experiences episodes of epigastric discomfort (‘like riding a rollercoaster’)
• He has episodes of staring into the middle distance. He smacks his lips during the events. (Automatism)
• He is sometimes confused for a minute after the event.

what seizure

Answer 10

temporal lobe seizure

Question 11

Case 2
• Mrs Black has suffered from ‘giggling’ fits all her life
• She had an episode where this giggling led to her head jerking to the right
• Her right arm then jerked and then her right leg
• This lasted 1/2 min
• Afterwards her right arm and leg felt weak for a couple of hours

Answer 11

gelastic seizure

- starts with giggling

Question 12

• Mr White has had 2 minute episodes of seeing multi-coloured flashing colours
• This is self limited and his vision returns to normal afterwards

Answer 12

simpel oral occipital seizure

Question 13

Mrs Yellow gets episodes where her whole left side tingles and she feels pins and needles.
• This lasts for a few seconds and is then gone.
• Sometimes she cannot use her left side and it feels weak afterwards.

Answer 13

focal onset right sided parietal seizure

Question 14

occipital seizure features

Answer 14

unformed images
flashing light to complex visual hallucinations
can go blindd
vision return to normal though

Question 15

temporal

Answer 15

complex aura
visceral disturbance 
memory 
supernatural 
automatism - stares into distance and loses himself

Question 16

frontal

Answer 16

Jacksonian march
todds paralysis
fencing posture with contraleteal head movement
arm extension with flexion of ipsilateral arm

Question 17

pariteal

Answer 17

Jacksonian march

paraethsia or tingling - all one side

Question 18

generalise tonic clonic seizures present as

Answer 18

abrupt loss of consciousness
everything becomes stiff - tonic phase - eyes open and pupils dilated and teeth clenched and breath held

muscles then begin to jerk after the 1st minute - tongue biting and blood sputum and eyes rolled back

Question 19

absence seizures usually during childhood 4-12

5-10 seconds of staring and Brough on by what

Answer 19

hyperventilation or phonic stimulus

Question 20

myoclonic seizures - juvenile

are sudden generalised muscle contractions and arm jerks when do they occur

Answer 20

in the morning

lifelong treatment of antiepiletpics - develop tonic and clonic seizures

Question 21

pneumonic for aetiology ( cause) of seizures

Answer 21

VITAMINS

Vascualr infections, trauma/toxins, autoimmune, metabolic imbalance, idiopathic , neoplasm, syndromes

Question 22

diagnosis

Answer 22

presenting features investigations and Ddi- ECG
CCTv footage of it

Drug history – tramadol, neuroleptics, vasodilators, older anti-depressants and prolongation of QTc – amitriptyline

Question 23

red flags to probable seizure events

Answer 23

Eyes open – eyes closed titely non epileptic

Tongue biting on side – indication of seizure

Cyanosis

Stertuous breathing- cannot breathe properly

Incontinence of urine (faeces)

Post Ictal recovery time - long

Post ictal state – all over pain, injuries, exhaustion

Question 24

• 1 year old presents with;
• Single episode where the baby went limp and then shook all 4 limbs
• Has been having ‘sniffles’
• Lasted 20 minutes
• Had a temperature of 38.8

is this an epileptic fit

Answer 24

no pyrexial fit

Question 25

* 12 year old was standing in assembly * Felt hot and sleepy and had been standing for 30 minutes * Fainted to the floor * All limbs shook whilst on the floor * Felt ok and back to normal afterwards epileptic fit ?

Answer 25

no went back to normal very quickly

Question 26

* 23 year old with a history of episodes where; * Feel them come on as see flashing lights * Get a bad headache at the back of her head * Associated with visual disturbances (flashing lights and zigzags) * Lasts hours and then goes * Feels tired afterwards * Has happened several times, normally with alcohol or poor sleep. epileptic siezure ?

Answer 26

no classic migraine

Question 27

• A 39 year old man walks up to the doctors station and says he is feeling like he is about to have a fit * Slowly falls to the floor backwards * Teeth clenched and eyes shut with all 4 limbs extended * Shakes all 4 limbs and then clenches their teeth again • Opens eyes to check if staff are attending * Pelvic thrusting * Bites the tip of the tongue * Lasts 20 minutes * Feels tearful afterwards

Answer 27

no psychical circumstance attention seeking

Question 28

differential diagnosis

Answer 28

``` syncope cardiac arrhymias non-epileptic attack malingering attack migraine ```

Question 29

what segment of PQRST complex can indicate seizure

Answer 29

long QT - blackout

Question 30

what drugs cause long QT interval

Answer 30

* Antiarrhythmic drugs * Certain non-sedating antihistamines (eg, terfenadine and astemizole) * Macrolide antibiotics * Certain psychotropic medications * Certain gastric motility agents (eg, cisapride, domperidone). Usually give antiepileptic on 2nd seizure

Question 31

driving what should happen if epileptic fit

Answer 31

Driving – everyone who has suffered an unprovoked seizure should contact the DVLA – and surrender their license until allowed to drive again 1st seizure – 6 months – 1 year off driving HGV 1 seizure – 10 years off driving Establish epilepsy – need to be seizure free for 12 months

Question 32

SUDEP

Answer 32

sudden unexplained death in epilepsy

Question 33

triggers of epilepsy

Answer 33

``` Alcohol (withdrawal) Drugs – Amphetamine, Ecstasy, Cocaine Drugs – enzyme inducers – can trigger quicker metabolism of anticonvulsantds so less essentially so seizure could occur Missed Anticonvulsants Pregnancy (part of eclampsia, 2 and third trimester (Enlarged volume of distribution) Infections – UTI/URTI Illness – poorly absorbed Anticonvulsants ``` prescriptions – amk

Question 34

what should you during a fit

Answer 34

cushion head and remove glasses, lossen tight clothing , recovery position afterwards, record time of seizure , don’t put anything in mouth not even to hold tongue , look for ID , don’t hold down ,as seizure ends offer help

Question 35

recuse therapy for epilepsy

Answer 35

buccal midszolam ( date rape drug) or rectal diazepam

Question 36

status epilepticus

Answer 36

over 5 mins of continuous seizures or over 2 discrete seizures between which there is an incomplete recovery of consciousness

Question 37

what do you give during status epilepticus

Answer 37

diazepam 10-20mg repeated once 15 mins later - pre hospital if easy lorazepam IV established phenytoin infusion

Question 38

for seizures you can always have surgery

Answer 38

hemispherectomy - outer layer of brain removed corpus collostomcy lobe removals or lobectomy bits of it