hrhodes's version from 2015-10-17 22:50


Question Answer
Define SeizureTransient disturbance of cerebral function due to abnormal paroxysmal discharge from brain - paroxysmal involuntary motor activity/behaviour;
What is lifetime risk of seizure?10%; if cause found, 5% repeat; if no cause found, 50% repeat
Define EpilepsyRecurrent primary seizures; 2+ seizures without acute provocation
Define Status Epilepticus2+ seizures without full recovery between / 5mins continuous convulsive seizures
Name 3 risk factors for statuschildren (1-3yrs; 50%), intellectual disability, >60yrs (often secondary to CVA);
How common is status epileptics?occurs in 16% adults and 25% children with known epilepsy; 25% non-convulsive
Define refractory statusOngoing despite 2 anti-epileptics; refractory in 9-30%


Question Answer
List the causes of seizuresIdiopathic; congenital; metabolic (hypoNa/Mg/Ca/G, PKU, ARF, inborn errors); traumatic; SOL; vascular (haem, infarct, SAH, AVM; degenerative; infections (herpes, encephalitis, meningitis); drugs; anticonvulsant compliance; sleep deprivation
What is the most common cause of new seizures in >65s CVA
A common cause of seizures in 35-65yrs SOL - 13%
List 7 drugs that cause sizersstimulants, theophylline, TCA, withdrawal, isoniazid, tramadol, antihistamines, clozapine
Causes of seizure in HIV ?mass lesion - toxoplasmosis/lymphoma, HIV encephalopathy, meningitis - TB, cryptococcal/bacterial; encephalitis - CMV, HZV., CNS TB, cystercosis, meurosyphillis


Question Answer
Describe the 2 phases of seizurePhase I - Increase metabolism and flow, Phase 2 - After 30mins, failure of compensation causing cerebral damage
What happens during phase 1?Incr cerebral blood flow and metabolism; incr BP/HR/temp/WCC/glucose, lactic acidosis
What happens during Phase II?Onset of irreversible cerebral damage after 30mins; compensation fails. Hypotension, decr cerebral blood flow, hypoG, hypoxia, arrhythmia, cardiac/renal/hepatic failure, DIC, rhabdo; aspiration; pul oedema; cerebral oedema; hyperkalaemia
Whats the general rule regarding duration (common sense)?duration progresses = permanent neurological damage more common


Question Answer
What are the main ways to classify seizures?Partial or generalised; Simple or complex
Describe a simple partial seizuremost common, GCS preserved, aura common, focal motor/sensory, sensory, autonomic, psychic
Describe a complex partial seizurealtered LOC, déjà vu, automatic/dystonic behaviour, post-ictal confusion, evolve over secs-mins, last 1+ mins, aura; usually arise from temporal lobe; temporal slowing/sharp waves EEG
List the different types of generalised seizure Absence, atypical absence, Tonic clonic, tonic, clonic, myoclonic jerks, atonic
Describe an absence seizuresudden onset and offset, altered LOC few secs, no aura, no post-ictal confusion, occasional minor motor movements, short, precipitated by hyperventilation, spike+waves 3Hz EEG
Describe a Tonic-clonic seizure altered LOC, cry, 30secs-2mins, post-ictal 30-60mins, mild headache; Todd’s paresis
Describe tonic, clonic and atonic seizures Tonic (drop attacks), Clonic (large amplitude jerking of body parts), Atonic (head and facial injuries)

Pregnancy and seizures

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Are there more or less seizures in epileptic pregnant women?17% increase in seizures
Which drugs cause neural tube defects?Valproate and carbamazepine
How can you reduced the risk in congenital defects in women on AED?Use single drug, split dosing to avoid peak, folic acid, vit K
In seizing women >20/40 what are the differential dx?Epilepsy (17% increase), PET, any cause of secondary seizure - trauma, drugs and withdrawal of drugs, ICH, non compliance

Neonatal seizures

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Seizures in neonates are treated differently that older kids, how?Phenobarbitone is first line 20mg/kg, then benzos, then can try pyridoxine and glucose
What are the differential diagnoses of neonatal seizures?1. Trauma - common! ICB in prematurity common or NAI, HIE - get tonal change, sepsis, metabolic - GLUCOSE (<2.7), electrolytes, inborn errors, drug withdrawal
If hypertensive, bradycardic and have papiloedema, what is first line?mannitl
In meninigitis causing seizure in neonate, what are the causative organisms?TORCHES - Toxoplasmosis, Rubella, CMV, Herpes, Syphillis


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What are pseudo seizures?mimic seizure, 70-80% women; non-synchronous movements, side-to-side head, averted eyes, pelvic thrusting, no cyanosis, no biting, loud, no post-ictal, positive avoidance manoeuvres
What are the differential diagnoses of seizure in children?Infantile spasm (sudden brief flexion of arms, head and trunk, in clusters), breath holding spells (after brief / vigorous cry, noxious stimulus), benign neonatal sleep myoclonus; benign focal epilepsy of childhood; nocturnal frontal lobe seizures; night terrors; ALTE
Investigations in 1st seizureBSL, FBC (inc WCC), U+Es, LFTs, VBG (RAGMA) CMP (PO4 low due to consumption), drug screen, anticonvulsant level, CK; ECG, CT head-could be done as OP
What is the ECG looking for? long QT
Would you do a CT head in first seizure?do as OP if full recovery and no cause suggested
What are the indications for immediate CT?SOL, ongoing altered LOC, fever, recent HI, PMH Ca, anticoag, ?HIV, change in seizure pattern, >40yrs, partial onset seizure, focal
Who would you do an LP on?<6/12; think it could be meng or encephalitis - treat first
What are the contraindications for LP? Suspected or confirmed raised ICP, Altered LOC
What are the pros and cons of LP in kids?Pros: mental state difficult to assess post-ictally; fulminant infxn require early diagnosis; quick; Cons: <5% have meningitis; traumatic to child / family; may cause meningeal seeding; coning, time consuming in ED
When is the best time to perform EEG?Within 48hrs of seizure - 70% positive
How do EEG help prognosticate?Predicts likelihood of further seizure in next 12/12. if normal, risk recurrence 12 months 15%, if abnormal, 40% risk
Does a normal EEG exclude epilepsy?Nope. only 50% epileptics will have abnormal 1st EEG
How do you tell if its a pseudo seizure pattern of activity and No RAGMA and no increase in prolactin


Question Answer
How do you manage seizures?O2, suctioning, coma position, trolley sides up, padded; treat cause
Medical treatment of seizures1. Midazolam 5-10mg iv (0.15mg/kg iv, IN, Buccal), repeat in 5mins, Phenytoin: 18mg/kg IV over 30mins (max 1g), valproate: 400-800mg (30mg/kg) IV over 3-5mins, Levetiracetam 20mg/kg, RSI
General principles of benzos1st line, anticonvulsant effects last 20-30mins; terminates status in 75-90%
What are the key differences when choosing benzos?Use midas. quick onset. DOA is shorter than lorazepam 1-6hrs, not 12-24hr, loran may have less reap depression
When would you consider paraldehyde?If no IV access / mentally handicapped / recurrent seizures - 0.3mg/kg PR
What would you give if a TB patient came in seizing?the same BUT early consideration of pyridoxine (IZD toxicity)


Question Answer
Whats the dose of phenytoin?Phenytoin: 15-20mg/kg IV over 30mins (max 1g)
What is the safe delivery rate for phenytoin?50mg/min, reduced to 25mg/min in elderly and those with known IHD
What is the onset, efficacy and benefits of phenytoin?onset 10-30mins; terminates status in 45-90%; give full dose even if on PO; causes less sedation than benzos; must be on cardiac monitor
What are the side effects and CI of phenytoin?SE: decr HR and BP (due to propylene glycol the preservative) and increased QT - Na channel effect; CI: 2/3rd deg HB, absence
What is the alternative that is not avaialbe in AU?Fosphenytoin - exact same dosing but given faster as no propyl glycol - less arrhythmia
Whats the dose of valproate?400-800mg (30mg/kg) IV over 3-5mins - 5mg/kg/min infusion
What are the differences between adult and children seizure management?Benzos and phenytoin are the same. Adults use valproate as 3rd, kids use phenobarbitone 18mg/kg
What is the trial being done comparing phenytoin and keppra for seizure cessation?ConSEPT trial
Whats the dose of Keppra and who is this especially good for?Levetiracetam 20mg/kg, young women unknown preg state

RSI and seizures

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What considerations would you have for RSI in refractory status?All the usual - optimisation; Timing - airway maintenance and control, oxygenation an issue, hypercapnea control if seizure related to HI, Drugs - paralytics mask seizure activity - use short acting depolarising agent - sux 1.5mg/kg - unless concerns re HyperK, propofol and ketamine both can have seizure cessation effects. In kids they like Thio
What would I use?Sux 1.5mg/kg; Ketamine 1.5mg/kg iv +/- fentanyl if HI
AlternativePropofol 1-2mg/kg - 5-10mg/kg/hr; rapid onset/offset
If given paralysis, what must happen?Continuous EEG monitoring

Discharge and driving

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When would you start anticonvulsant on discharge? only if precipitant found that cannot be treated, or prolonged recurrent febrile seizures (clobazam)
What are the key education points?safety, esp in children-bathing, supervision, swimming. DRIVING
What are the key driving education points?It is the patients responsibility to report to the DVA that they have had a seizure. Driving exclusion period depends on cause of seizure
How long can you not drive for?single seizure on withdrawal of medications on medical advice: 3/12
Sleep deprivation3/12
Generalised seizure with illness3/12
Isolated seizures, partial, recent diagnosis6/12
While driving, seizure during normal waking hours1yr Psych illness/non-compliant with meds: 2yrs


Question Answer
RF for recurrence<50yrs, FH seizures, 2nd seizure within 1/52, SOL, prev neuro injury, abnormal EEG, seizure during sleep, Todd’s paresis
When do most recurrences happen and what is the risk? within 2yrs; 30% risk recurrence in children, 75% after 2nd seizure
What is the mortality rate for status22%! (3-8% in children)
Mortality rates in status are time dependent what are the respective mortality rates pre and post 1 hour duration ?<5% and >30% respectively

Outpatient drugs

Question Answer
Phenytoin usesgeneralised TC seiures, psychomotor seizures
Phenytoin SE: nystagmus, ataxia, slurred speech, confusion, allergy, N+V+C, hepatotoxicity, haem, lymphadenopathy, gingival hyperplasia
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Carbamazepine (Tegretol) usesgeneralised TC seizures, partial seizures, chronic pain
Carbamezipine SEataxia, dizziness, sedation, SJS/skin reactions, blood dyscrasia, hepatotoxicity, SIADH
Na valproate (Epilim) usesgeneralised TC seizures, partial
Sodium Vlaproate SEdecr plt, hepatotoxicity, incr NH3, teratogenicity
Ethosuximide usesabsence only
Ethosuximide SE: hepatotoxicity, blood dyscrasia, SJS, GI Sx
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Vigabatrin usesdifficult epilepsy
Vigabatrin SEvisual field defect, psychosis, incr appetite
Lamotrigine usesgeneralised, partial
Lamotrigine SE: SJS, TEN, aseptic meningitis
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Gabapentin usessecondary generalised, partial, difficult epilepsy
Levetiracetam usespartial, myoclonic - becoming more widely used