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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