YES Another talk about blackouts BECAUSE IT IS

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 SEIZURE 3/100 WILL HAVE TWO OR MORE 2 -3 X GREATER MORTALITY PSYCHOSOCIAL HANDICAP 20 -30% “intractable” epilepsy is NOT ~50% of “status” is psychogenic SOME NASTY THINGS CAUSE SEIZURES SOME EPILEPSIES ARE INHERITED Some 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 >20 years 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 Ig. A 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 5 mg 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 • (50 ml of glucose 50% solution IV) • (50% not suitable for children) • GIVE thiamine if alcohol abuse suspected • (10 ml of Pabrinex IV over 10 minutes) • Lorazepam 4 mg IV If seizures persist after 10 minutes Consider: Pseudostatus/Non Epileptic attacks • FOSPHENYTOIN DOSE 15 mg phenytoin equivalent (PE) per kg IV • (See Detailed Management Outline for administration details) If seizures persist after 20 minutes: Transfer to ICU Consider: Pseudostatus/Non Epileptic attacks Paraldehyde Phenobarbitone (on ICU)

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