The Diagnosis and Treatment of Epilepsy and AEP Drugs

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Differential Diagnosis of Seizures

Syncope
Cardiac Arrhythmia
Panic Attack
Transient Ischemic Attack
Narcolepsy with Cataplexy
Psychogenic
Breath Holding Spells in Children

First Seizure Patients

Should be screened for symptoms and signs of an acute medical/neurological illness

Common Causes of First Seizures

Illicit Drugs
Electrolyte Imbalance
Meningitis/Encephalitis
Cardiorespiratory Dysfunction
Liver/Kidney Function

Evaluation of First Seizure

History/Physical
Blood Test - CBC, Electrolytes, Ca, Mg
Hepatic/Renal Function
Lumbar Puncture for Infection
Blood/Urine Screen for Drugs
EEG
MR of Brain

Most useful tool for classifying Seizure

EEG

Generalized Seizure in EEG

Generalized spike/Wave pattern in all lines

Partial Onset Seizures in EEG

Spike/Wave pattern in only one line

Imaging choice for Seizure Pts

MRI

Absence Seizures

No Aura/Warning
Motionless with Blank Stare
Eyelid Fluttering or Other Automatisms
Short Duration
Little Postictal Confusion
Hyperventilation Precipitates
Photosensitivity
3 Hz spike wave

Temporal Lobe Complex Partial Seizure

Aura of Autonomic, Psychic, Epigastric, Olfactory
Arrest of Movement
Oroalimentary Automatisms
60 - 90 Seconds
Postictal language disturbance when in dominant hemisphere
Confused with gradual recovery
Amnesia for event

Partial Onset Seizure

Another name for Temporal Lobe Complex Partial Seizure

Myoclonic Seizure

Myoclonus
Focal, Regional, or Generalized
Single or Repetitive
Various Amplitudes
Hallmark of Juvenile Myoclonic Epilepsy

Generalized Tonic Clonic Seizure

Generalized or Partial in Origin
Initial extension of extremities (Tonic)
Muscle Jerks (Clonic)
Unresponsive 15 - 20 min after
Tongue Biting and Urinary Incontinence

Common Features of Seizures

Tonic/Clonic Movements
1-2 Min
Postictal Confusion

Hallmarks of Seizures

Tongue Biting
Postictal Focal Signs

Syncope Common Features

Sweating and Pallor
Brief 5 - 15 sec
Stiffening/Brief Clonic
Little confusion after

Hallmarks of Syncope

Precipitated by Pain
Attacks when sitting/standing

Differences in Antiepileptic Drugs

No differences in Efficacy
Adverse Effects, Pharmacokinetic, Expense differ
Should prescribed based on differences

Monotherapy vs Multi therapy

Start with Mono
Mono has less SE

Goal of Therapy

No seizures
No Side effects
Often therapeutic range will not be same for all pts

Partial Seizure Drug of Choice

Carbamazepine
Phenytoin

Generalized Onset Drug of Choice

Valproate

Least Drug Interaction / Protein Binding Drug

Levetiracetam

Least Sedating Drug

Lamotrigine

Least Tolerated Drug

Phenobarbital
Primidone

Serum Levels of AEP Drugs

Should be used as a guideline
Should be measured
Should be determined based on pt reaction

Phenytoin Increases in Dose

< 7 mg/mL - Increase by 100 mg
7 - 11 mg/mL - Increase by 50 mg
> 11 mg/mL - Increase by 30 mg

Removing Multiple Drug Therapy

Remove the sedatives first
Withdraw over the course of months

Protein bound drugs

Can displace other protein bound drugs
Measure free drug and bound drug

Drugs that induce Metabolism of Other Drugs

Carbamazepine
Phenytoin

Drugs that inhibit Metabolism of Other Drugs

Valproate

Drugs that are Highly Protein Bound

Valproate
Phenytoin

When to stop Therapy

If seizure free for 2 - 4 yrs
The longer seizure free, the better the outcome

Drug Withdraw

Should be done over a period of 2 - 6 months

Child Therapy

Pharmacokinetics can vary from adults
Can also vary based on age of child

AEP Drugs and Pregnancy

Should receive High dose Folic acid if on drugs
Use lowest possible dose
Monotherapy
Valproate and Phenobarbital is the worst

Two most common seizures in adults

Generalized Tonic Clonic
Complex Partial Seizure

Generalized Tonic-Clonic Seizure Symptoms

Sudden Cry/Fall
Rigidity then Muscle Jerks
Shallow Breathing/Apnea
Urinary Incontinence
1 - 2 Min in duration
Postictal confusion

Generalized Tonic-Clonic Seizure What to do

Turn on side
Keep airway clear
Protect from environment
If first seizure go to hospital
If longer than 5 min or multiple seizures should administer tx for status epilepticus

Generalized Tonic-Clonic Seizure What not to do

Nothing in mouth
Don't hold Tongue
No artificial respirator until after jerks

Complex Partial Seizure Symptoms

Blank Stare, chewing, random activity
Unaware of surroundings
Unresponsive to commands
1 - 2 minutes
Postictal confusion
Memory Loss

Complex Partial Seizure What to do

Speak Calmly
Protect from Environment
If First time take to hospital
Babysit postictal

Complex Partial Seizure What not to do

No grabbing
No Restraining
No shouting

When to take someone with Seizure to hospital

First Time
Pregnant
Diabetic

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