YES!

Another talk about blackouts.

BECAUSE:

• IT IS COMMON • IT IS BADLY MANAGED• IT CAN RUIN LIVES • IT IS INTERESTING• YOU CAN DO A LOT

plan

• Recognition & investigation• Safety Advice • Old & New drugs• pregnancy • Status epilepticus

6/100 WILL HAVE ONE SEIZURE3/100 WILL HAVE TWO OR MORE

2-3X GREATER MORTALITYPSYCHOSOCIAL HANDICAP20-30% “intractable” epilepsy is NOT~50% of “status” is psychogenic

SOME NASTY THINGS CAUSE SEIZURES

SOME EPILEPSIES ARE INHERITEDSome epilepsy can be cured – surgery!

“BLACKOUT ?CAUSE”………….

Hughlings – Jackson (1870)

born Green Hammerton Nr York.

A convulsion is but a symptom, and implies only….A disorderly discharge of nerve tissue on muscles.It occurs with all sorts of conditions of ill health,At all ages, and under innumerable circumstances.

Seizures are:

• SUDDEN.• SHORT• STEREOTYPED.

• Tongue biting• Clustering, associations• Where do they wake up?

POSITIVE SYMPTOMS usually A SEIZURE.

NEGATIVE SYMPTOMS usually FOCAL ISCHAEMIA.

MIGRAINE OFTEN A MIXTURE, + “MARCH”

Multiple & stereotyped attacks RARE in TIA, (?monocular vision)In epilepsy & migraine pattern of spread NOT vascular territry.

Altered awareness much more common in seizure & psychogenic

Diplopia not seizure, Deja vue not vascular.

video

When in doubt?

• GET A WITNESS (home video).• The diagnosis is clinical.• WAIT AND SEE. More harm-if false

positive.• The EEG does NOT diagnose

epilepsy.• Video-telemetry can be useful.

classification

• Most epilepsy presenting >20years is of focal onset or acute symptomatic eg alcohol

• Childhood “idiopathic” ep. Is characterised by well defined electroclinical syndromes.

classification

Primary generalised

Partial simple complex

Secondary generalisation

classification

• Childhood absence (3-10) female

• Juvenile absence (7-16)

• Juvenile myoclonic

• Ep with T-C on waking

• Benign with Rolandic spikes

• Benign occipital

Differential diagnosis

• Reflex syncope, posture etc• Cardiac syncope, rhythm, valves etc• Perfusion failure, hypovolaemia, autonomic

failure.• Psychogenic, NEA, Panic, breath holding.• Migraine• TIA• Narcolepsy/cataplexy.• Hypoglycaemia.

treatment

• ONE DRUG• START LOW – GO SLOW

• TOXICITY• TERATOGENICITY• INFORMATION

treatment

• Carbamazepine• Valproate• Lamotrigine• Gabapentin• Tiagabine• Topiramate• levetiracetam

Chronic toxicity

• Memory/cognitive, behaviour, cerebellar atrophy, neuropathy

• Retinopathy

• Acne, hairy, alopecia, chloasma

• Liver enzyme induction

• IgA deficiency, SLE

• Megaloblastic, thrombocytopaenia

chronic toxicity

• Decreased thyroxine, increased cortisol/sex hormone metabolism

• Osteomalacia

• Gum hypertrophy, coarse features, Dupuytrens.

safety advice

• DVLA: THE LAW!• Pilots, ships captains.• Swimming, climbing, hang gliding, scuba

diving.• Machines? (unwarranted job

discrimination)• Too much restriction is usual.• Sleep deprivation• alcohol

Pregnancy:

Advise in advance.Risk from uncontrolled seizures > teratogenicity.Lowest dose, single drug, avoid valproate.Folic acid 5mg daily, min 3/12 before trying.

UK pregnancy register, RVH Belfast.

teratogenicity

• 0.5% all pregnancies

• Monot 4-6%

• Two 7-8%

• More 15-20%

status

• A-B-C, glucose, thiamine.• Look for a cause? • Alcohol, stroke, tumour, infection…• Drug withdrawal• Psychogenic NEAD.

Convulsive status epilepticus: Adult treatment protocol

Brief Management Overview(see Detailed Management Outline for more information)

•Oxygen

•GIVE glucose if BM is low •(50ml of glucose 50% solution IV)•(50% not suitable for children)

•GIVE thiamine if alcohol abuse suspected •(10ml of Pabrinex IV over 10 minutes)

•Lorazepam 4mg IV

If seizures persist after 10 minutes  

•Lorazepam 4mg IV

If seizures persist after 10 minutes Consider:Pseudostatus/Non Epileptic attacks

•FOSPHENYTOIN DOSE15mg phenytoin equivalent (PE) per kg IV •(See Detailed Management Outline for administration details)

If seizures persist after 20minutes: Transfer to ICU

Consider:Pseudostatus/Non Epileptic attacks

ParaldehydePhenobarbitone (on ICU)

•General anaesthesia with Thiopentone or Propofol

information

• British Ep Assoc. www.epilepsy.org.uk

• The National Soc for Ep. www.epilepsynse.org.uk

• DVLA: 01792-772151

• www.gov.uk/at_a_glance/content.htm

• Smith & Wallace, “A clinicians guide to epilepsy.” Arnold 2001