Another talk about blackouts. 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 2-3X 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 >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   Consider: Pseudostatus/Non Epileptic attacks FOSPHENYTOIN DOSE 15mg phenytoin equivalent (PE) per kg IV (See Detailed Management Outline for administration details) If seizures persist after 20minutes: Transfer to ICU Paraldehyde Phenobarbitone (on ICU) General anaesthesia with Thiopentone or Propofol FOSPHENYTOIN 750mg = 500mg PHENYTOIN EQUIVALENTS (PE) NB: THIS DOCUMENT ONLY APPLIES TO ADULTS SEE SEPARATE DOCUMENT FOR TREATMENT OF STATUS EPILEPTICUS IN CHILDREN

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