2. Talley & O’Connor p400-402  Causes of unconsciousness = C.O.M.A.  CO 2 narcosis (uncommon)  Overdose  Metabolic/endocrine  Apoplexy (Stroke or other CNS insult)  General inspection  DRABC  Posture (neck extension, decerebrate, decorticate)  Involuntary movements

3. Talley & O’Connor p400-402  Level of consciousness  GCS  Coma, stupor, drowsy, alert  AVPU: Alert, Voice response, Pain response, Unresponsive  Neck  Trauma, stiffness, Kernig’s sign  Head  Inspect, palpate, Battle’s sign

4. Talley & O’Connor p400-402  Face  General  Asymmetry, jaundice, myxoedema  Eyes  Pupils, fundus, haemorrhage, position, movement  Ears and nostrils  Blood and CSF  Mouth and tongue  Trauma, corrosion, gum hyperplasia, breath odor

5. Talley & O’Connor p400-402  Limbs  Trauma, needle marks, tone, reflexes, pain response  Trunk  Trauma, heart, lungs, abdomen  Other  Urine  Blood sugar  Body temp  Stomach contents (if indicated)

6. Harrison’s chap 363 Partial seizure – discrete CNS focus  Simple – fully conscious  Motor, sensory, autonomic, or psychic symptoms  May progress (eg Jacksonian march)  May proceed to complex partial seizure  May proceed to general seizure  Complex – impaired consciousness  Preceded by aura (simple partial seizure)  Automatisms – unconscious behaviour  Postictal confusion, anterograde amnesia

7. Harrison’s chap 363 Generalized seizure – affects both hemispheres  Absence seizure (petit mal)  Brief lapse of awareness  Subtle motor signs (eg blinking)  No post-ictal confusion  Tonic-clonic seizure (grand mal)  10-20s general muscle contraction (tonic)  Periods of relaxation (clonic)  Post ictal flaccidity and unresponsiveness, then impaired consciousness, confusion, headache, fatigue  Atonic seizure  Brief loss of postural control and impaired consciousness  No post-ictal confusion  Myoclonic seizure  Sudden, brief muscle contraction  Focal or generalized  Eg jerk while falling asleep

8. Harrison’s chap 363 Epilepsy syndromes (disorders featuring epilepsy)  Juvenile myoclonic epilepsy  Responds well to anticonvulsants  Lennox-Gastaut syndrome  Underlying CNS disease, poor prognosis  Mesial temporal lobe epilepsy syndrome  Refractory to anticonvulsants  Responds well to surgery  Other examples with known genetic basis

9. Harrison’s chap 363 Causes of seizures  Neonates  Perinatal hypoxia, infection, drug withdrawal, trauma, metabolic, genetic, developmental  Children  Febrile, trauma, developmental, infection, genetic, idiopathic  Adolescents  Trauma, drugs, brain tumour, infection, genetic, idiopathic  Young adults  Trauma, drugs, brain tumour, alcohol withdrawal, idiopathic  Older adults  Trauma, CVA, brain tumour, alcohol withdrawal, metabolic disorder, degenerative CNS, idiopathic

10. Harrison’s chap 363 Mechanisms of seizures  Initiation and propagation  high-frequency action potentials bursts  Hypersynchronization  Interstitial and synaptic funkiness with electrolytes and neurotransmitters  Funkiness spreads to surrounding areas  Epileptogenesis  Normal neural network becomes hyperexcitable  Injury? Development?  Genetic  Ion channelopathies

11. Harrison’s chap 363 Antiepileptic drugs block initiation or propogation  Inhibit Na + -dependent action potentials:  phenytoin, carbamazepine, lamotrigine, topiramate, zonisamide  Inhibit voltage-gated Ca 2+ channels:  Phenytoin  Decrease glutamate release:  Lamotrigine  Potentiate GABA receptor function:  benzodiazepines and barbiturates  Increase GABA availability:  Valproic acid, gabapentin, tiagabine  Modulate release of synaptic vesicles:  Levetiracetam  (Probably) Inhibit T-type Ca 2+ channels in thalamic neurons:  Ethosuximide and valproic acid

12. Harrison’s chap 363 Approach to seizure management

13. Harrison’s chap 363 Approach to seizure management

14. Harrison’s chap 363 DDx of seizures  Syncope  Vasovagal, arrythmia, hypotension, cardiac failure  Psychological  Panic attack, psychogenic seizure, hyperventilation  Metabolic  Hypoglycemia, hypoxia, alcoholic blackout, DTs, psychoactive drugs  Migraine  TIA  Sleep disorders  Narcolepsy, cataplexy, benign sleep myoclonus  Movement disorders  Tic, nonepileptic myoclonus, paroxysmal choreoathetosis  Special considerations in children  Breath-holding, apnea, night terrors, migraine, benign paroxysmal vertigo

15. Harrison’s chap 363 Treatment of seizures and epilepsy  Treat underlying condition  Avoid precipitating factors  Antiepileptic drugs  Big table of doses and adverse effects  Some patients can eventually cease drug therapy

16. Harrison’s chap 363 Treatment of seizures and epilepsy  Surgery  focal neocortical resection  anteromedial temporal lobe resection  Amygdalohippocampectomy  Lesionectomy  multiple subpial transection  Multilobar resection  Hemispherectomy  Corpus callosotomy

17. Harrison’s chap 363 Status epilepticus  Continuous seizures  Repetitive seizures with impaired consciousness between  GCSE = generalized convulsive status epilepticus  GCSE > 5min is an emergency:  cardiorespiratory dysfunction, hyperthermia, metabolic derangement, irreversible CNS injury  EEG may be required to show seizure activity after 30-45 minutes

18. Harrison’s chap 363 GCSE management  ABC and hyperthermia  IV access, lab tests for metabolic abnormalities  Anticonvulsants  Begin with Lorazepam  Valproate?  Phenytoin or Fosphenytoin  Admit to ICU if seizures continue  General anesthesia (propofol, midazolam, pentobarbital)

19. Harrison’s chap 363 Ongoing epilepsy management  Interictal behavior  Depression, memory deterioration, postictal psychosis or anxiety  Psychosocial issues  Cultural stigma, fears of death and mental retardation  Employment, driving, other activities  Legislation varies  Mortality  Underlying disease, Accidents, GCSE, SUDEP – Sudden unexpected death in epileptic patients

20. Harrison’s chap 363 Special issues for women with epilepsy  Catamenial epilepsy  Association of seizures with menstruation  Pregnancy  Seizure frequency may increase or decrease  Teratogenic effect of antiepileptic drugs  Contraceptive pill  Interactions with medication  Breastfeeding  Drugs are expressed in breast milk, but no evidence of long term harm to infants