A patient has come in to discuss their epilepsy diagnosis. They want to know about SUDEP , their risk and what they can do about it.
-discuss lifestyle factors eg alcohol, new medications which may interact incl otcs, sleep hygiene, GI disturbances, importance of adherence to medications
- explain risk is low but that it is a risk
- many people have seizures and are complication free
- aknowledge and legitimise the risk: ‘eg many people worry about seizures, theyre obviously unpleasant’
having seizures is bad
some seizures have complications: rarely this includes serious injury and death
some lifestyle choices impact on seizure frequency
arming patients with information to reduce impact of epilepsy is good.
discuss DVLA requirements of epilepsy. patient has had second seizure in a year
- must inform DVLA
- license is rebuked but they get it back if they are seizure free for 1 year
- this includes aura, jerking, and aura, absence etc seizures
- try to persuade patient, use personal factors eg own and family safety, feeling of guilt if they end up killing someone, void insurance
- wider public safety
- criminal offence
- doctor will need to inform DVLA anyway if they don’t
A 23 year old lady is started on Lamotrigine following her first focal seizure. She is also on the OCP. Explain the drug to her and highlight any points for consideration in the discuss
- takes a brief hx
-explains why lamotrigine has been chosen and when to take it - explain ocp can have reduced effect with lamotrigine
-explain risk of all aeds with pregnancy
-explain side effects of Lamotrigine: common : sedation, dizziness, nausea, insomnia,
rare but important side eggects are allergic skin rash and hypersensitivity reaction.
-emphasise should seek medical attention if these rarer side effects occur
what is the acute management of status epilepticus?
Ensure airway patency if possible - 100% oxygen via rebreathe mask or nasal cannula
1st line: IV Lorazepam or Buccal or IM Midazolam (or other BDZ)
If still continuing then REPEAT BDZ
if still continuing then IV Valproate or IV Phenytoin
After 30 minutes use propofol to stop convulsion and ring ITU and Neuro
A patient presents following their first ever TLOC. They recover well and are able to go home that day. What investigation is most important?
- An ECG
All patients with TLOC must have an ECG to check for evidence of potentially life threatening cardiac rhythm disturbances (Eg prolonged QT). An EEG is rarely indicated after a first ever seizure and should never be performed in patients who give a history consistent with syncope. In patients who recover fully after TLOC and have no abnormal neurological signs on examination, immediate brain imaging is unnecessary. Such patients do need to be seen in a ‘first seizure’ clinic and MRI brain scanning may well be organised as an outpatient. MRI is far better for spotting small epileptogenic lesions than CT.
what is a febrile seizure?
common seizures in childhood. they occur after a high temperature (eg secondary to an URTI)
they can predispose people to seizures in later life
particularly seizures which originate in the temporal lobe as they can cause Mesial Temporal Sclerosis
(scarring and gliosis which is visible on MRI)
when is serum drug monitoring of anti epileptic medication indicated?
- if there are concerns over drug toxicity
- if there are concerns over compliance /adherence/ poor absorption
- if there are concerns that another medication may have interacted with the anti epileptic medication and may be causing the drop
what issues are involved in switching anti epileptic mediations?
- pt needs to simultaneously reduce current drug and increase new drug (in order to avoid breakthrough seizures)
- the new drug may be less effective than the old!
- potential interactions of the two medications
- new side effects
- potential interactions between the new drug and any other medication she may be on ESP contraception OCP
- implications for driving: if she experienced a break through seizure she would not be allowed to drive … also the DVLA recommend (but don’t legally enforce) that patients do not drive during the changeover period
what implications does epilepsy have on a patient’s hobbies etc
best to avoid things such as extreme sports, showers safer than baths, heavy machinery is no no , cant drive,
ultimately , apart from the driving, it is up to the patient to make an informed decision about what level of risk they consider to be acceptable. A doctor or nurse can help them think this through.
what can cause seizures
- poor sleep
- systemic illness
- GI upset (poor absorption)
- alcohol
- dehydration
- electrolyte abnormalities
- blood glucose
- new medication
- missing medication (on purpose and by accident)
derangements in which electrolytes can lead to limb weakness?
- calcium
- magnesium
- potassium
- phosphate
what are signs of worsening breathing due to GBS ?
- weak neck
- worse lying flat
- worsening GBS signs (limb weakness)
what does an LP in GBS show?
- normal WCC
- high protein
signs of neuromuscular weakness causing resp problems?
- CO2 retention flap
- neck weakness
- reduced chest expansion
treatment for GBS
-plasma exchange or IVIG
supportive tmt: eg ventilator support & pulse and BP monitoring, DVT prophlaxis (heparin or enoxaparin)
what would the LP look like in a patient with neuropathy secondary to HIV look like?
high WCC (probably lymphocytes)
causes for GBS
- EBV
- CMV
- Campylobacter Jejuni
what is the most common form of GBS?
AIDP
acute inflammatory demyelinating polyradiculopathy
investigations to order in GBS?
- Nerve conduction studies
- LP
- LFTs (can get derangement)
- spirometry
- antiganglioside antibody
what is brown sequard syndrome?
-damage to a hemi section of the spinal cord
standard investigation for carpal tunnel?
nerve conduction studies
what investigations are required to diagnose Bells palsy?
- none
- clinical diagnosis
treatment of Bells palsy
- steroids
- some treat with acyclovir
- tape eye shut
how long does it take to recover from Bells palsy?
-may worsen after first few days
4-6 months
recurrence is also low
