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Flashcards in seizure disorders Deck (80)
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1
Q

definition of a seizure?

A

sudden, excessive, disorderly d/c of neuronal activity in the brain

  1. sudden or transient
  2. involves motor, sensory, autonomic, or psychic manifestations
  3. temporarily alters systemic arousal
  4. often manifests as convulsions but there are many diff kinds of seizures
2
Q

Definition of seizure disorder/epilepsy?

A
  • tendency to have recurrent seizures in absence of any immediately tx cause such as hypoglycemia or ETOH withdrawal
  • may also manifest as strange sensations, emotions, and/or behavior including convulsions, muscle spasms, and LOC
3
Q

Definition of a convulsion?

A
  • bodies muscles contract and reflex rapidly and repeatedly, resulting in an uncontrolled shaking of the body
4
Q

Pathophys of epilepsy?

A

A: result of complex genetic mutations and enviro factor can cause:

  1. abnormal brain wiring
  2. chemical (NT) imbalances
  3. abnorm connections made when attempting to repair an injury

B: hypersensitive neurons may exhibit a sudden or violent depolarization:

  1. epileptogenic (able to cause epilepsy)
  2. easily act by hyperthermia, hypoxia, hypoglycemia, hyponatremia, sensory stim, certain sleep phases

C. epileptogenic neurons fire more intensely, more often, and with greater amplitude than normal neurons

  1. at threshold pt, cortical excitation spreads to subcortical, thalamic and brain stem areas
  2. inhibitory neurons in cortex, anterior thalamus, and basal ganglia react to cortical excitation
5
Q

Incidence of seizures?

A
  • b/t 0.3-0.7% of US pop
  • approx 2 mill Americans have seizure more than 1/month
  • prevalence: highest in children b/t 2-5 and at puberty
  • second highest incidence of 1st time seizures occurs in pts over 50 yo (usually caused by trauma, stroke)
  • seizures can begin at any time of life
  • 2-4% of all persons in developed countries have recurrent seizures at some time during their lives
  • idiopathic or primary generalized epilepsy is generally apparent by time of puberty
  • seizures beginning after age 20 are usually due to a focal process or metabolic derangement
6
Q

Etiology of seizures?

A
  • infancy and childhood: birth injury, infection, trauma, metabolic disorders, congenital brain abnormality
  • adolescence: trauma, metabolic disorders
  • young adult: trauma, ETOH, neoplasms
  • middle age: vascular disease, neoplasms
  • late life: vascular: strokes, neoplasms
  • other causes: physiologic stress: sleep deprivation, fever (esp in kids), withdrawal from ETOH or sedative drugs
7
Q

Diff b/t provoked and unprovoked seizures?

A
- provoked: triggered by certain provoking factors  in an otherwise healthy brain:
metabolic abnorm
ETOH withdrawal
illict drug intoxication and withdrawal
high fever in kids

-unprovoked seizures: occur in setting of persistent brain pathology

8
Q

How do seizures often manifest?

A
  • as strange sensations, emotions and behaviors (including convulsions)
  • many may experience the same seizure events over and over, while some have many diff types of seizures that cause diff sxs each time
  • pts should be eval thoroughly after an initial seizure (complete hx)
  • in some cases: other conditions must be ruled out such as an arrhythmia
9
Q

What does the type of seizure a person has depend on?

A
  • area of brain affected
  • underlying cause
  • focal or generalized
  • occurrence during wakefulness or sleep
  • known triggers
10
Q

What may exacerbations of known previously controlled seizures be due to?

A
  • noncompliance with meds
  • ETOH use
  • menses
11
Q

Mortality/morbidity of pts with seizures?

A
  • 2-3x greater than the general pop
  • most deaths are due to underlying cause of epilepsy
  • the remainder are due to accidents (trauma, burns, aspiration), suicide, and sudden unexpected death (SUDEP)
12
Q

What is SUDEP?

A
  • defined as sudden, unexpected, non traumatic non drowning death in a pt with epilepsy
  • accounts for 1/1000 deaths among the general pop with epilepsy and perhaps 50% of pts with refractory epilepsy
13
Q

Social issues that affect seizure pts?

A
  • relationships
  • financial costs
  • school/employment
  • driving
  • recreational activities
14
Q

Psych issues in seizure pts?

A
  • emotional difficulties
  • depression, anger, anxiety and or fear
  • cognitive problems
  • some people with epilepsy may have developmental delays
15
Q

Phases of seizures: prodrome?

A
  • may experience feeling, sensations or changes in behavior hours or days before seizure
  • common sxs:
    deja vu, smells, sounds, taste
    fear/panic
    dizzy/lightheaded
    HA
    nausea
16
Q

Phases of seizures: aura?

A
  • first sx of a seizure and considered part of seizure
17
Q

Middle phase of seizure?-

A
  • called ictal phase
  • begins from 1st sx to end of seizure
    common sxs: loss of awareness (blackout), blurred vision, flashing lights confused, feeling spacey, difficulty talking, unable to swallow, repeated blinking of eyes, lip smacking or chewing movements
18
Q

Ending phase of a seizure?

A
  • called postictal phase
  • recover immediately or minutes to hours
  • common sxs:
    slow to respond, sleepy, confused, injuries: bruising, cuts, broken bones, HA, nausea
19
Q

Seizure classification?

A
- focal: seizure activity starts in one area of the brain: focal - 
retain awareness (w/o impairment of consciousness) or focal with altered awareness (w/ impairment of consciousness) 
  • generalized: activity involves both hemispheres of the brain - absence (petit mal), tonic-clonic (grand mal), myoclonic, clonic, tonic, atonic
20
Q

Definition of LOC?

A
  • a state of complete or partial unawareness or lack of response to sensory stimuli as a result of hypoxia caused by respiratory insufficiency or shock; from metabolic or chemical brain depressants such as drugs, poisons, ketones, or electrolyte imbalance; or from a form of brain pathologic condition such as trauma, seizures, cerebrovascular insult, brain tumor, or infection
21
Q

Categories of focal seizures?

A
- intial d/c arises from a focal, unilateral area of the brain w/o impaired consciousness
categories -
motor (jacksonian march)
sensory
autonomic 
psychic
22
Q

Jacksonian march seizure?

A
  • initiated with abnorm electrical activity within the primary motor cortex
  • ***unique in that they travel through the primary motor cortex in succesion, affecting the corresponding msucles, often beginning with the fingers. This is felt as a tingling sensation
  • it then affects the hand and moves on to more proximal areas
  • other sxs often assoc with Jacksonian seizure are sudden head and eye movements, tingling, numbness, smacking of the lips, and sudden muscle contractions
23
Q

Focal seizures w/o impaired consciousness?

A
  • prodrome or aura: warning sign of impending seizure activity
  • todd’s paralysis: temporary, unilateral - 30 min to 36 hrs
  • can progress very quickly from a seizure (no change in consciousness) to a seizure (consciousness altered - staring spell, automatisms) or generalized seizure (tonic-clonic) seizure
  • pt may not recal aura, EEG will show focality
24
Q

Focal seizures with impaired consciousness?

A
  • produce unresponsiveness
  • 70-80% arise from temporal lobe
  • most common type of seizure
  • clinical signs, sxs, and supporting EEG changes indicate involvemtn of 1 hemisphere at onset
  • lasts from 30 s to 2 minutes
  • many evolve from simple focal seizures: simple partial onset followed by impaired consciousness
  • some may present with impairment of consciousness at onset
  • present with automatisms (set of brief unconscious behaviors - finger rubbing, lip smacking, chewing, sleep walking)
  • confusion and tiredness may follow for about 15 min, may take hours to be fully normal
25
Q

Clincial sxs of generalized onset seizures?

A
  • disturbances in consciousness

- involve varying bilateral degrees of symmetric motor responses w/o evidence of localization to one hemisphere

26
Q

examples of generalized onset seizures?

A
  • absence (petit mal)
  • myoclonic
  • atonic (drop)
  • febrile seizure
  • idiopathic tonic-clonic (grand mal)
  • post traumatic epilepsy
27
Q

What are absence seizures?

Typically occur in?

A
  • generalized non-convulsive epileptic events
  • expressed mainly as disturbances in consciousness
  • referred to as petit mal seizures
  • can evolve into generalized motor seizures
  • onset and termination of attacks are abrupt
  • typically occur in childhood and cease in adulthood (grade school children doing poorly in school should potentially be screened)
28
Q

Examples of abscence seizure presentations?

A
  • blank stare
  • motionless
  • stop talking mid sentence
  • can have mild clonic, tonic, or atonic components
  • may have automatisms
  • no postictal period
29
Q

Characteristics of atypical absence seizures?

A
  • lapses of awareness that have gradual onset
  • don’t resolve as abruptly
  • are accompanied by autonomic features or loss of muscle tone
  • occur most often in children with mental impairment
  • don’t respond as well to antiepileptic drug tx
30
Q

Myoclonic seizures?

Range?

A
  • rapid recurrent brief muscle jerks that can occur:
    bilaterally, unilaterally, synchronously, asynchronously

myoclonic jerks can range from:

  • small movements that simultaneously affect the head, limbs, and trunk
  • may terminate into generalized tonic-clonic (grand mal) seizure
  • can occur at any time
  • often cluster shortly after waking or while falling asleep
31
Q

What are atonic seizures?

A
  • drop attacks
  • occur most often in children with diffuse encephalopathies
  • are characterized by sudeen loss of muscle tone that may result in falls with self injury
  • can occur in repetitive, rhythmic and successive manner
32
Q

What are febrile seizures? Occurs in what population?
diff types?
Tx for prolonged seizures?

A
  • fever is most common cause of convulsions in children
  • occur b/t 6 m-5 y
  • temp usually higher than 38 C (100.4 F)
  • chance of recurrence is greatest if first seizure occurs b/f 1 year or there is a family hx
  • are not assoc with nor do they cause mental impairment, poor school performance or behavioral problems

2 types: simple and complex

  • during body becomes stiff and arms and legs begin twitching
  • lose consciousness
  • blood test, imaging, and EEG generally not needed
  • tx with IV lorazepam only for prolonged seizures
33
Q

What is a tonic clonic seizure?

A
  • “grand mal” - generalized tonic-clonic seizure, is a major motor seizure which involves all extremities and characterized by a sudden LOC
  • it may be either primary (ex: arising from deep brain structures) or represent a focal seizure with secondary generalization
34
Q

Tonic part of tonic-clonic seizures?

A
  • characterized by sudden LOC
  • becomes rigid and falls to ground
  • respiration is arrested
  • usually lasts for less than a minute
35
Q

Clonic part of tonic-clonic seizures?

A
  • jerking of body musculature
  • may last for 2-3 minutes
  • folowed by stage of alt level of consciousness
36
Q

What may occur during tonic-clonic seizures?

A
  • tongue and lips may be bitten
  • urinary or fecal incontinence
  • pt may be injured
  • immed following:
    may recover consciousness
    drift into sleep
    have further convulsions w/o recovery of consciousness b/t attacks (status epilepticus)
37
Q

Postictal phase of tonic-clonic seizures?

A
  • HA
  • disorientation
  • confusion
  • drowsiness
  • nausea
  • soreness of muscles
38
Q

What is a secondary generalized seizure?

signs and sxs?

A
  • seizure that becomes generalized (spread to both sides of brain) after initial event (focal seizure) has already begun
  • 30% of people with focal epilepsy
  • usually last 1-3 min, but may take a lot longer for a person to recoveer
  • may begin with aura or simple focal seizure
  • signs/sxs:
    stiffening of muscles
    LOC
    tongue/cheek may be bitten
    tonic/clonic phases
  • consciousness returns slowly and person may be drowsy, confused or agitated
39
Q

Dx secondary generalized seizure?

Tx?

A
  • Dx: EEG, MRI

- tx: carbamazepine

40
Q

Occurence of post traumatic epilepsy?

Causes?

A
  • depends on degree of head injury
  • majority develop seizures within 1-2 years
  • 2/3 have focal or secondarily generalized seizures
causes - head injuries:
penetrating head wounds
cerebral hematoma
intracerebral hematoma
unconsciousness or amnesia lasting more than 24 hrs
41
Q

Dx seizures - 3 objectives?

A
  • 1) determine if pt has epilepsy
  • 2) classify seizures and type of epilepsy accurately and determine if clinical data fit a particular epilepsy syndrome
  • 3) ID, if possible, specific underlying cause
42
Q

What is impt in hx of pt with seizures?

A
  • pts description of the experience: aura?
  • witness’s accurate observation
  • how it started
  • at what age
  • family hx
  • hx of focal trauma or other insult
  • recent drug use
  • ETOH (withdrawal)
  • hx of CNS infection
  • hx of event: recent onset - in adults may indicate new intracranial lesion
    chronically sustained or remote hx: suggests chronic epilepsy
  • do they occur at particular time?
  • are they exacerbated by: emotional stress, menstruation, fever
  • other known provocations: flashing lights
  • drugs - Rx and other
43
Q

What is impt to look for on PE?

A
  • exam b/t seizures show no abnormality
  • lateralized or focal signs postictally suggest seizures may have focal origin
  • Postictal (Todd’s) paralysis?
  • other focal abnorm?
  • bruits? heart murmur?
44
Q

Workup of seizure pt? What are other conditions that can mimic a seizure?

A
  • is it a seizure?
  • 4 conditions can mimic a seizure:
    REM behavior disorder
    TIA
    transient global amnesia
    migraine
45
Q

What is REM behavior disorder? How is dx made?

A
  • parasomnia that consists of sudden arousals from REM sleep immed followed by complicated, often aggressive, behaviors for which the pt is amnestic
  • dx is clarified by overnight sleep testing
46
Q

Characteristics of a TIA?

A
  • may last seconds to minutes
  • characterized by neg sxs and signs (weakness or visual loss)
  • postictal state may include lateralizing “negative” sxs such as weakness
47
Q

What is transient global amnesia?

A
  • condition of vascular etiolgy
  • occurs after age of 50
  • deficit of short term memory that begins abruptly and persists for minutes to hours, w/o other cognitive or motor impairment
  • episodes can be recurrent
48
Q

Migraine manifestations?

A
  • migraine auras such as visual illusions and basilar migraine sxs, including altered consciousness, can mimic complex partial seizures
  • HA that follows complex partial and generalized tonic clonic seizures is migrainous in quality and duration
49
Q

Most impt dx test for epilepsy?

A
  • EEG
  • classifying seizures correctly
  • ID epileptic syndromes
  • making therapeutic decision
  • to be completely dx - must be obtained during seizure activity
  • 40-50% of pts show epileptiform abnorm in their initial EEG
  • capture of epileptiform activity is enhanced by sleep deprivation for 24 hrs so that pts sleep during a portion of EEG recording
50
Q

Imaging in dx epilepsy?

A
  • MRI: **study of choice
    should be obtained in all pts over 20 suspected of having epilepsy for possibility of underlying neoplasm
  • should be obtained on all children with partial seizures, abnorm neuro finding, or focal slow wave abnorm on EEG
  • ID structural brain patho
  • CT: alt choice
51
Q

Labs needed in epilepsy dx?

A
  • est baseline
  • AED levels
  • acute/chronci syst disease:
    CMP
    TSH
    CBC
    drug screen (blood or urine)
    blood sugar levels
  • lumbar puncture if indicated
  • EKG
52
Q

What is status epilepticus?

Causes?

A
  • any seizure lasting more than 30 min or a prolong flurry of seizures w/o return to previous level of consciousness b/t seizures
  • life threatening, esp if generalized tonic-clonic status, if pt arrives in ED still seizing, assume they are in SE and tx accordingly

Causes: drug noncompliance or sudden withdrawal, fever, drug or alcohol withdrawal

53
Q

What is 1st thing you should assess in pt with status epilepticus?

A
  • ABCs
    airway: roll to side, head tilt, and oral airway
    breathing: oxygen, intubation
    circulation: cardiac monitor, maintain blood pressure
54
Q

Tx status epilepticus?

A
  • blood draw for glucose, lights, Ca, Mg, CBC, drugs of abuse, AED levels
  • start IV and give thiamine and glucose
  • ativan (lorazepam) 2 mg/min
  • fosphenytoin (20 mg/kg) IV or
    phenytoin 20/Kg IV
  • if above not effective after 20 minutes: phenobarbital 20 mg/Kg IV (watch respirations), deacon 15-20 mg/kg IV
  • if cont failed measures then general anesthesia with ventilator assistance with neuromuscular jxn blockade
55
Q

Tx for refractory Status epilepticus?

A
  • pentobarbital coma
  • midazolam (versed) drip
  • propofol (diprivan) drip
  • cont monitoring
56
Q

Tx of provoked seizures?

A
  • tx directed to provoking factor
57
Q

Tx of unprovoked seizures?
1st seizure
2nd seizure

A
  • 1st seizure: usually no tx
  • tx can be initiated if risk of reoccurence is high
  • 2nd seizure:
    dx of epilepsy is established and risk of 3rd seizure is high
  • most physician tx at this stage
  • in children some may wait for 3rd seizure
58
Q

Tx options for seizures?

A
  • neuro referral!!!
  • meds
  • surgery
  • ketogenic diet
  • vagal nerve stimulator
  • biofeedback
59
Q

effective tx % in pts with seizures?

A
  • approx 60% of pts achieve seizure control after 1st year
  • 15% achieve control at later date
  • 25% continue to have seizures despite tx
  • selection depends on seizure type and SE/toxicity profile
  • MOA of each med plays role in what type of seizure for which it may be effective
60
Q

3 basic MOAs of seizure meds?

A
  • affecting voltage dependent Na or Ca channels: Na+ channel blockers effective for tonic-clonic and partial seizures, T-type CCBs effective for absence seizures
  • increasing inhibitory neurotransmission (GABA)
  • decreasing excitatory neurotransmission (glutamate and aspartate)
61
Q

Common meds used to tx seizures?

A
  • dilantin (phenytoin)
  • tegretol (carbamazapine): 1st line for focal and generalized tonic-clonic
  • depacon (valproic acid): 1st line for atypical absence
  • phenobarbital
  • zarontin (ethosuximide): first line for absence
  • Valium (diazepam)
  • ativan (lorazepam)
  • klonipin (clonazepam)
62
Q

Newer antiseizure meds?

A
  • neurontin (gabapentin)
  • lamictal (lamotrigine)
  • felbatol (felbamate)
  • topamax (topiramate)
  • trileptal (oxcarbazepine)
  • zonigran (zonisamide)
  • gabitril (tiagabine)
  • cerebyx (fosphenytoin)
63
Q

Common SEs of antiseizure meds?

A
  • lethargy
  • memory difficulties
  • cognitive or concentration difficulties
  • cog or concentration difficulties (diff staying focused)
  • hyperactivity
64
Q

Levitiracetam (keppra)

SEs

A
  • 2nd line for generalized tonic-clonic
  • dosage based on medical condition, kidney fxn, and response to tx:
    1000-3000 mg qday or BID
    steady state achieved in about 2 days
SEs: 
somnolence
ataxia
HA
behavioral changes

Preg C

65
Q

Carbamazepine (tegretol)?
Use?
MOA?
SEs? Warnings?

A
  • 1st line for focal and gen tonic-clonic
  • blocks Na+ channels
  • dosage: 800-1200 mg qd, divided doses bid-qid
  • start at 200 mg PO bid
  • therapeutic range: 4-12 mg/L
  • preg D
  • AEs: bone marrow suppression, liver toxicity, rash
  • monitor CBC, LFTs
  • warnings: serious and sometimes fatal derm rxns to include toxic epidermal necrolysis and SJS
66
Q

Phenytoin (dilantin) use?
MOA?
SEs, warnings?
Monitor?

A
  • first line for focal and gen tonic-clonic
  • alters Na+ and Ca2+ conductance membrane potentials
  • blocks sustained high frequency repetitive firing
  • high doses: inhibits release of serotonin and NE, promotes uptake of dopamine, inhibits monoamine oxidase activity
  • dosage: 300-400 mg PO in divided doses qd-tid
  • IV dilantin pt must be on *cardiac monitor
  • Preg D

SEs: gingival hypertrophy**, hirsutism, coarsened facial features, megaloblastic anemia, lupus like syndrome

  • monitor: CBC, LFTs, plasma levels (steady state plasma concentration of 10-20 mcg/ml (reached in 5-10 days)
  • warning: CV risk assoc with rapid infusion ( cardiac monitor)
67
Q
Valproic acid (depakote)
use?
Preg category?
SEs?
Monitor?
A
  • first line for focal, generalized tonic-clonic, absence, atypical absence, myoclonic, and atonic
  • MOA: increases level of GABA
  • dosage: 10-15 mg/kg/d po in divided doses
  • increase by 5-10 mg/kg/day q 7 days, max 60 mg/kg/d
  • preg D

SEs: tremor, wt gain, liver dysfxn (high risk under age 2 - BBW), pancreatitis, teratogenic effects

  • monitor: LFTs, CBC, and drug levels
    therapeutic range: 50-100 mg/L
68
Q

Lamotrigine (lamictal)
use?
Preg?
SEs?

A

first line for focal and absence
- ***effective in tx of children with newly dx absence seizures

  • MOA: stabalizes neuronal membranes by acting on AA release and inhibiting NA+ channels
  • dosage: 250 mg PO bid
  • pregnancy C
  • SEs: dizziness, HA, nausea, somnolence, skin rash (BBW: SJS)
69
Q
Gabapentin (neurontin)
use?
MOA?
Preg?
SEs?
A
  • second line for focal and generalized tonic-clonic
  • MOA: reduce presynaptic GABA release
  • dosage: 300-1200 mg PO tid
  • pregnancy C
  • SEs: somnolence, dizziness, ataxia HA, tremor
70
Q
Topiramate (topramax)
use?
MOA?
Preg?
SEs?
monitor? 
Caution?
A
  • first line for focal
  • MOA: blocks Na+ channels, enhancing GABA activity
  • dosage: 200-600 mg/day
  • pregnancy C
  • SEs: somnolence, fatigue, dizziness, cognitive slowing, paresthesias, nervousness, confusion
  • monitor: liver and renal status
  • Caution: narrow angle glaucoma, and kidney stones (keep pt hydrated)
71
Q
Phenobarbital 
use?
MOA?
Preg?
SEs?
Warnings?
Monitor?
A
  • second line for focal and generalized tonic-clonic
  • MOA: enhances GABA, interferes with transmission of impulses from thalamus to cerebral cortex
  • dosage: 60 mg PO bid-tid
  • preg D
  • SEs: sedation in adults and children, irritability, restless muscle movements in eyes, tongue, jaw
  • warnings: sleep apnea, COPD, renal problems, suicide
  • monitor: drug concentration=therapeutic range 15-40 mg/L, CBC, LFTs
72
Q
Ethosuximide (Zarontin)
use?
MOA?
Preg?
SEs?
Monitor?
A
  • 1st line use for absence
  • MOA: depresses motor cortex
  • dosage: 40-100 micrograms/ml
  • Preg: C
  • SEs: stomach aches. cramps, N/V, hiccups, drowsiness, fatigue, rashes, SLE, bone marrow suppression
  • monitor hepatic disease and renal impairment!
73
Q
Oxcarbazepine (Trileptal)
Use?
MOA?
Preg?
SEs?
A
  • 1st line for focal
  • MOA: blocks voltage sensitive Na+ channels, stabilizes neural membranes, inhibits repetitive firing, and decrease synaptic impulse propagation
  • metabolized/excreted: liver/urine
  • preg C
  • dosage: 600 PO bid
  • SE: HA, N/V, somnolence, hyponatremia, angioedema, severe rash
74
Q
Felbamate (felbatol)
use?
MOA?
Preg?
SEs?
A
  • 2nd line for focal, and generalized tonic-clonic
  • MOA: inhibitory effects of GABA and benzodiazepine receptor binding
  • met/excreted: liver/urine
  • preg C
  • pt has to sign risk acknowledgement form to take (not a good pick)
  • SEs: wt loss, nausea, insomnia, HA, hepatic failure, aplastic anemia (bone marrow suppression), suicide
75
Q
Zonisamide (zonegran)
use?
MOA?
preg?
SEs?
A
  • only for adjunctive therapy for focal (w/o impairment of consciousness)
  • MOA: blocks voltage dep Na+ and Ca2+ channels, metabolized/excreted: liver/urine and feces
  • preg: C
  • sleepiness, dizziness, rash, fever, sore throat, easy bruising
  • don’t use in pts with renal failure (CrCl of less tha 50 ml/min), and children
76
Q

Tiagabine (gabitril)

  • Use
  • MOA
  • Preg
  • SEs
  • monitor?
A
  • 2nd line for focal
  • MOA: increases GABA activity in CNS
  • met/excreted: liver/feces and urine
  • Preg C
  • give to kids older than 12 yo
  • SE: dizziness, tiredness, nervousness, weakness, confusion
  • monitor: CBC, renal fxn test, LFTs, and blood chemistry
77
Q

Meds summary?

A
  • many reqr baseline Cr
  • newer meds less sedating, more expensive
  • goal: mono-therapy
  • start low, don’t stop abruptly
  • monitor CBC and LFTs
  • most preg women with epilepsy should continue seizure meds, and if possible take single AED at lowest dose possible
  • potential benefits outweight risk
  • Can D/C drugs when pt hasn’t had seizure for 3 years
  • reduction should be gradual over weeks to months, should be withdrawn one at a time
  • if seizures reoccur - tx is reinstituted with prev regimen
78
Q

Alt therapies?

A
  • DON’T REPLACE DRUGS
  • biofeedback
  • ketogenic diet (high fat/low carb) - body burns fat insteda of glucose for energy, usually used in kids refractory to AEDs
  • vagal nerve stim: implantation of device to stim vagus nerve, to abort the seizure
79
Q

Surgery options for epileptic pts?

A
  • anterior temporal lobectomy
  • corpus callosotomy
  • amygdala-hippocampectomy
  • VNS
80
Q

Educating epileptic pts?

A
  • avoid sleep deprivation and ETOH
  • avoid jobis that involve working at heights, near heavy machinery, flames or burners
  • restrictions on careers:
    firefighter, commercial driver, airline pilot
  • never swim alone
  • most sports are permitted
  • but caution on:
    hang gliding
    scuba
    mountain climbing
    skydiving