EPILEPSY &THE DENTAL PATIENT. Manifestations of Seizure Attack: Isolated, brief seizure Isolated,...
-
Upload
hillary-black -
Category
Documents
-
view
218 -
download
2
Transcript of EPILEPSY &THE DENTAL PATIENT. Manifestations of Seizure Attack: Isolated, brief seizure Isolated,...
EPILEPSY &THEEPILEPSY &THEDENTAL DENTAL PATIENTPATIENT
Manifestations of Seizure Manifestations of Seizure Attack:Attack:
Isolated, brief seizureIsolated, brief seizure - Tonic-clonic movement of trunk & extremities- Tonic-clonic movement of trunk & extremities - Loss of consciousness- Loss of consciousness - Vomiting- Vomiting - Airway obstruction- Airway obstruction - Loss of urinary & anal sphincter control- Loss of urinary & anal sphincter control
Epilepsy :Epilepsy : Recurrent seizures attacks Recurrent seizures attacks
Repeated or sustained seizure (Status Repeated or sustained seizure (Status Epileptics)Epileptics)
Seizure vs EpilepsySeizure vs Epilepsy
Seizures
CardiovascularDrug relatedSyncopeMetabolic (glucose, Na, Ca, Mg)Toxic (drugs, poisons)InfectiousFebrile convulsionsPseudoseizureAlcohol/drug withdrawalPsychiatric disordersSleep disorders (cataplexy)
Nonepileptic Epilepsy(Recurrent Seizures)
Idiopathic(primary)
Symptomatic(secondary)
EpilepsyEpilepsy Definition:Definition: a a state of recurrent seizuresstate of recurrent seizures, ,
not due to an identifiable metabolic causenot due to an identifiable metabolic cause May be due to :May be due to :
Underlying genetic or congenital factors Underlying genetic or congenital factors Cerebral insult prenatally or later in lifeCerebral insult prenatally or later in life
Background:Background: 1 – 2% of the general population has seizures1 – 2% of the general population has seizures PrimaryPrimary
Idiopathic epilepsy: onset ages 10-20Idiopathic epilepsy: onset ages 10-20 SecondarySecondary
Precipitated by one of the following:Precipitated by one of the following: Intracranial pathologyIntracranial pathology
Trauma, Mass, Abscess, InfarctTrauma, Mass, Abscess, Infarct Extracranial PathologyExtracranial Pathology
Toxic, metabolic, hypertensive, eclampsiaToxic, metabolic, hypertensive, eclampsia
Causes of EpilepsyCauses of Epilepsy
Seizure TypesSeizure Types Generalized Convulsive Seizures (Grand Generalized Convulsive Seizures (Grand
Mal):Mal): Tonic , clonic movements, (+) LOC, apnea, Tonic , clonic movements, (+) LOC, apnea,
incontinence and a post ictal stateincontinence and a post ictal state Non Convulsive Seizures (Petit Mal)Non Convulsive Seizures (Petit Mal)
BBrief lapse of consciousness that may last rief lapse of consciousness that may last only a few seconds.only a few seconds.
Absence seizures – “blank staring spells”Absence seizures – “blank staring spells” Myoclonic – brief contractions of selected Myoclonic – brief contractions of selected
muscle groupsmuscle groups Partial SeizuresPartial Seizures
Characterized by presence of hallucinationsCharacterized by presence of hallucinations Simple = somatic complaints + no LOCSimple = somatic complaints + no LOC Complex = somatic complaints + AMS or LOCComplex = somatic complaints + AMS or LOC
Types of EpilepsyTypes of Epilepsy
Epilepsy PrecipitantsEpilepsy Precipitants What might cause an otherwise stable patient to have a What might cause an otherwise stable patient to have a
seizure?seizure? Forgetting to take anticonvulsantForgetting to take anticonvulsant Stress –Emotional/PhysicalStress –Emotional/Physical Sleep disturbanceSleep disturbance HypoglycaemiaHypoglycaemia Alcohol withdrawalAlcohol withdrawal
Other medicationsOther medications Anticonvulsants – withdrawal from – esp. benzodiazepinesAnticonvulsants – withdrawal from – esp. benzodiazepines AntidepressantsAntidepressants AntipsychoticsAntipsychotics AntihistaminesAntihistamines AntibioticsAntibiotics CNS stimulantsCNS stimulants
Theophylline, caffeine, cocaine, amphetamineTheophylline, caffeine, cocaine, amphetamine Nonsteroidal anti-inflammatory agentsNonsteroidal anti-inflammatory agents OpiatesOpiates
Epilepsy : Potential Epilepsy : Potential problems:problems:
1.1. Precipitation of the attack.Precipitation of the attack.
2.2. Problems of Problems of drugsdrugs taken taken
a)a) PhenytoinPhenytoin-------- Gingival hyperplasia ------ Gingival hyperplasia
b)b) ValproateValproate-------- Bleeding tendancy------ Bleeding tendancy Most epileptic seizures are self-limited .Most epileptic seizures are self-limited . If more than 1 seizure—consider the If more than 1 seizure—consider the
possibility of underlying abnormality—possibility of underlying abnormality—e.g.e.g. electrolyte disturbance, hypoglycaemiaelectrolyte disturbance, hypoglycaemia
Status Epilepticus :Status Epilepticus : Seizures that are Seizures that are prolonged—prolonged—i.e.i.e. longer than 10 minutes or longer than 10 minutes or that re-occur without the patient regaining that re-occur without the patient regaining normal consciousnessnormal consciousness
Approach for SeizureApproach for Seizure Turn person on side with face turned toward ground to keep Turn person on side with face turned toward ground to keep
airway clear, protect from nearby hazardsairway clear, protect from nearby hazards DO NOT put any object in mouth or restrainDO NOT put any object in mouth or restrain As always ABC’s First As always ABC’s First IV, O2, Monitor.IV, O2, Monitor.
Send blood for CBC, Chemistry, Tox screen as appropriateSend blood for CBC, Chemistry, Tox screen as appropriate Anticonvulsant levelsAnticonvulsant levels Prolactin levels / Lactate levelsProlactin levels / Lactate levels
For seizures that are prolonged—For seizures that are prolonged—i.e.i.e. longer than 5 minutes or longer than 5 minutes or that re-occur without the patient regaining normal that re-occur without the patient regaining normal consciousness – Rx with: Lorazepam consciousness – Rx with: Lorazepam
Is patient still seizing? Post ictal? Pseudoseizure?Is patient still seizing? Post ictal? Pseudoseizure? Complete History and Physical ExamComplete History and Physical Exam
Including detailed Neuro ExaminationIncluding detailed Neuro Examination Repeat Neuro evaluations a must!Repeat Neuro evaluations a must!
Transfer to hospital needed for:Transfer to hospital needed for: Multiple seizures or status epilepticusMultiple seizures or status epilepticus Person is pregnant, injured, diabeticPerson is pregnant, injured, diabetic New onset seizuresNew onset seizures
Medical Treatment of First Medical Treatment of First Seizure(s)Seizure(s)
•Whether to treat first seizure is controversial ?
•16-62% will recur within 5 years
•Relapse rate for second seizure is reduced by AEDs,
BUT long term prognosis of whether the patient will have refractory epilepsy is not
•Increased risk of relapse
Abnormal imaging
Abnormal neurological exam
Abnormal EEG
Family history of epilepsy
•Currently, most patients are not treated for the first seizure unless there is an increased risk for relapse
ANTIEPILEPTIC DRUGSANTIEPILEPTIC DRUGS
Phenytoin Carbamazepine Sodium
Valproate Phenobarbital Primidone
Gabapentin Lamotrigine Topiramate Tiagabine Oxcarbazepine Levetiracetam Zonisamide Pregabalin
1st Generation
2nd Generation
After seizure attackAfter seizure attack
1.1. Place on side and suction Place on side and suction airwayairway
2.2. Monitor vital signsMonitor vital signs3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22
5.5. Prepare to ERPrepare to ER
1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Midazolam 3mg/min IV or Midazolam 3mg/min IV or
IMIM3.3. Phenytoin10~15mg/kg IVPhenytoin10~15mg/kg IV
1.1. Suction airwaySuction airway2.2. Monitor vital signsMonitor vital signs3.3. Administer OAdminister O22
4.4. OBSERVE for at least OBSERVE for at least 1hr and consult 1hr and consult physicianphysician
Patient UnconsciousPatient Unconscious Patient ConsciousPatient ConsciousIf su
sta
ined
If su
sta
ined
Dental treatment of the E pileptic pati ents AEDs
1. Patient handling
-C hair position -P atient’s head -F alse teeth
2 . Adequate history -Naaaaa aa aaaaaaa -Saaaaaa aaaaaaa -M edi cat i on compl iance
3 . Treatment planni ng
-S t ressf ul si t uaaaaa -a hot i c st i mul aaaaa -Hypogl ycemi a - 4 . Education dentalstaff
Prevention of Peri-operative Prevention of Peri-operative SeizuresSeizures
Patients must take their anticonvulsant Patients must take their anticonvulsant medicationmedication
If general anaesthetic – anaesthetist should be If general anaesthetic – anaesthetist should be aware of seizure tendencyaware of seizure tendency
Check patient’s pre-operative anticonvulsant Check patient’s pre-operative anticonvulsant levelslevels
Consult with patient’s neurologist or family Consult with patient’s neurologist or family physicianphysician
Most stable epileptics, well-controlled on Most stable epileptics, well-controlled on medication, can undergo surgery without medication, can undergo surgery without difficulty or complicationdifficulty or complication
aaaaaaaa a& AED
1. Unexplained oral manifestations eg. tttttt tt tttttt ttttttttttt tt ttt tttttt t,, , tttttttt ttttttt;,
A granulocytosis, Thrmbocytopenia
2. Signs of liver damage
3. Signs of lymphadenopathyttttttt-ttttttt tttttttt
Valproate & Lamotrigine
- - Stevens Johnson syndrome
- Stevens Johnson syndrome (valproate),
nausea, ataxia
Status EpilepticusStatus Epilepticus
DefinitionDefinition Operationally defined as seizure lasting Operationally defined as seizure lasting
greater than 5-10 minutes OR two seizures greater than 5-10 minutes OR two seizures
between which there is incomplete recovery between which there is incomplete recovery
of consciousness.of consciousness. ““Recurrent seizures with failure to Recurrent seizures with failure to
recover from one seizure before next recover from one seizure before next seizure begins”seizure begins”
Status EpilepticusStatus Epilepticus A medical emergencyA medical emergency Adverse consequences can include hypoxia, Adverse consequences can include hypoxia,
hypotension, acidosis and hyperthermiahypotension, acidosis and hyperthermia
Goal: stop seizures as soon as possibleGoal: stop seizures as soon as possible
HypoxiaHypoxia Lactic acidosisLactic acidosis HypercarbiaHypercarbia RhabdomyolysisRhabdomyolysis HyperpyrexiaHyperpyrexia HypoglycaemiaHypoglycaemia
Hypertension Hypertension (early)(early)
ArrhythmiasArrhythmias Neurogenic Neurogenic Hypotension (late)Hypotension (late) AspirationAspiration Injury, burns etcInjury, burns etc
AetiologyAetiology TumourTumour Cerebrovascular disease Cerebrovascular disease Head injuryHead injury Infection Infection Hypoxic encephalopathyHypoxic encephalopathy Drug abuse / overdose / withdrawalDrug abuse / overdose / withdrawal Metabolic Metabolic Primary epilepsy Primary epilepsy PseudoepilepsyPseudoepilepsy
TreatmentTreatment ABC & oxygen & IV accessABC & oxygen & IV access Glucose if indicated or unsure (50mls/D50 Glucose if indicated or unsure (50mls/D50 Diazepam or lorazepam IV (or PR)Diazepam or lorazepam IV (or PR) Phenytoin (to terminate SE or prevent further Phenytoin (to terminate SE or prevent further
fits)fits) Monitor ECG and BPMonitor ECG and BP Investigate & monitor (EEG)Investigate & monitor (EEG) Persistent: Persistent:
> Further phenytoin > Further phenytoin > Phenobarbitone > Phenobarbitone
> Thiopentone > Thiopentone Propofol Propofol
PrognosisPrognosisDepends onDepends on AetiologyAetiology AgeAge Duration of statusDuration of status Systemic complications (anoxia)Systemic complications (anoxia) Treatment givenTreatment given
Mortality: 3 – 35%Mortality: 3 – 35%
Responding to a Patient Experiencing a Responding to a Patient Experiencing a ConvulsionConvulsion
After seizure attackAfter seizure attack
1.1. Place on side Place on side and suction and suction airwayairway
2.2. Monitor vital Monitor vital signssigns
3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22
5.5. Prepare to ERPrepare to ER1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Dormicum 3mg/min IV or Dormicum 3mg/min IV or
IMIM3.3. Dialantin 10~15mg/kg IVDialantin 10~15mg/kg IV
1.1. Suction airwaySuction airway2.2. Monitor vital Monitor vital
signssigns3.3. Administer OAdminister O22
4.4. OBS for at least OBS for at least 1hr and consult 1hr and consult physicianphysician
Patient unconsciousPatient unconscious Patient consciousPatient consciousIf susta
ined
If susta
ined
Seizures vs EpilepsySeizures vs Epilepsy
Definition:Definition: the clinical the clinical manifestation of an manifestation of an abnormal and abnormal and excessive excitation of excessive excitation of a population of cortical a population of cortical neuronsneurons
Incidence:Incidence: approximately approximately 80/100,000 per year80/100,000 per year
Lifetime prevalence:Lifetime prevalence: 9% 9% (1/3 benign febrile (1/3 benign febrile convulsions)convulsions)
Definition: a tendency toward recurrent seizures unprovoked by systemic or neurologic insults
Incidence: approximately 45/100,000 per year
Point prevalence: 0.5-1% 14 years or younger
13% 15 to 64 years
63%65 years and older
24%
Cumulative risk of epilepsy through 74 years old: 1.3% - 3.1%
Seizures Epilepsy
STROKE and TIASTROKE and TIA Cerebrovascular disease is the most common Cerebrovascular disease is the most common
cause of neurologic disability in Western cause of neurologic disability in Western countriescountries
Major types of cerebrovascular disease:Major types of cerebrovascular disease: Cerebral insufficiencyCerebral insufficiency InfarctionInfarction HaemorrhageHaemorrhage Arteriovenous malformationArteriovenous malformation Stroke = Ischaemic lesionsStroke = Ischaemic lesions
TIA = transient ischaemic attackTIA = transient ischaemic attack Focal neurologic abnormalities of sudden Focal neurologic abnormalities of sudden
onset and brief duration (usually minutes, onset and brief duration (usually minutes, never more than a few hours) that reflect never more than a few hours) that reflect dysfunction in the distribution of either the dysfunction in the distribution of either the internal carotid-middle cerebral or the internal carotid-middle cerebral or the vertebral-basilar arterial systemvertebral-basilar arterial system
StrokeStroke
80% involve the carotid system80% involve the carotid system 33rdrd leading cause of death in US and Canada leading cause of death in US and Canada Major cause of disabilityMajor cause of disability Most stroke survivors die of myocardial diseaseMost stroke survivors die of myocardial disease
Stroke – Unmodifiable RisksStroke – Unmodifiable Risks
Age – majority occur in individuals >65Age – majority occur in individuals >65 Male genderMale gender Race – higher incidence in African AmericansRace – higher incidence in African Americans HeredityHeredity
Stroke – Modifiable RisksStroke – Modifiable Risks
HypertensionHypertension Diabetes mellitusDiabetes mellitus Cigarette smokingCigarette smoking AlcoholAlcohol ObesityObesity HyperlipidaemiaHyperlipidaemia Cardiac disease – esp. previous myocardial Cardiac disease – esp. previous myocardial
infarction and atrial fibrillationinfarction and atrial fibrillation Haematologic factors – Haematologic factors – e.g.e.g.
hyperhomocystinaemiahyperhomocystinaemia
Treatment of Acute StrokeTreatment of Acute Stroke
In a non-post-operative patient, tPA (tissue In a non-post-operative patient, tPA (tissue plasminogen activator) can be given plasminogen activator) can be given intravenously within 3 hours of onset of stroke intravenously within 3 hours of onset of stroke symptoms and intra-arterially within 6 hourssymptoms and intra-arterially within 6 hours
The best treatment is preventionThe best treatment is prevention
Stroke PreventionStroke Prevention
Risk factor modificationRisk factor modification AspirinAspirin
Dose between 81 and 325 mg/dayDose between 81 and 325 mg/day Ticlopidine (TiclidTiclopidine (Ticlid®)®) Clopidogrel (Plavix®)Clopidogrel (Plavix®) ASA/persantine (Aggrenox®)ASA/persantine (Aggrenox®)
WarfarinWarfarin
Stroke and SurgeryStroke and Surgery For elective surgery – delay for 2-3 months post-For elective surgery – delay for 2-3 months post-
eventevent Do not stop ASA or antiplatelet agentDo not stop ASA or antiplatelet agent Remember high incidence of ischaemic coronary Remember high incidence of ischaemic coronary
artery disease in patients with TIA or strokeartery disease in patients with TIA or stroke Surgical trauma associated catecholamine release Surgical trauma associated catecholamine release
leads to platelet activationleads to platelet activation Platelet activation promotes platelet aggregation Platelet activation promotes platelet aggregation
and hypercoagulabilityand hypercoagulability Aspirin is not routinely started in the immediate Aspirin is not routinely started in the immediate
peri-operative periodperi-operative period Even in high risk patients already taking aspirin, it Even in high risk patients already taking aspirin, it
is generally discontinued a week prior to elective is generally discontinued a week prior to elective surgery to improve intra-operative hemostasissurgery to improve intra-operative hemostasis
Stroke and SurgeryStroke and Surgery The risk-to-benefit ratios of administering The risk-to-benefit ratios of administering vsvs withholding withholding
aspirin in the immediate peri-operative period have never aspirin in the immediate peri-operative period have never been assessed and comparedbeen assessed and compared
There are no large randomized controlled trials available to There are no large randomized controlled trials available to guide usguide us
WHAT DOES THE LITERATURE SAY?WHAT DOES THE LITERATURE SAY? Gaspar et al. – Department of Oral and Maxillofacial Gaspar et al. – Department of Oral and Maxillofacial
Surgery, Rambam Medical Center, HaifaSurgery, Rambam Medical Center, Haifa CONCLUSION:CONCLUSION: discontinuing low-dose aspirin prior to discontinuing low-dose aspirin prior to
elective oral surgery is not justifiedelective oral surgery is not justified Harefuah 1999 136:108-10Harefuah 1999 136:108-10
Sonksen Sonksen et al. – et al. – Dept. of Anaesthesia, City Hospital, Dept. of Anaesthesia, City Hospital, Birmingham, UKBirmingham, UK
Conclusion: Conclusion: in healthy volunteers the defect in in healthy volunteers the defect in haemostasis has largely disappeared 48 hours after the last haemostasis has largely disappeared 48 hours after the last dosedose British Journal of Anaesthesia 1999 82:360-5British Journal of Anaesthesia 1999 82:360-5
Aspirin and SurgeryAspirin and Surgery Bartlett – Department of Plastic, Reconstructive, Bartlett – Department of Plastic, Reconstructive,
Hand and Maxillofacial Surgery, Middlemore Hand and Maxillofacial Surgery, Middlemore Hospital, Auckland, New ZelandHospital, Auckland, New Zeland
Conclusion: Conclusion: it is unnecessary to stop aspirin before it is unnecessary to stop aspirin before minor dermatologic plastic surgeryminor dermatologic plastic surgery British Journal of Plastic Surgery 1999 52:214-6British Journal of Plastic Surgery 1999 52:214-6
Ardekian et al. – Department of Oral and Ardekian et al. – Department of Oral and Maxillofacial Surgery, Rambam Medical Center, Maxillofacial Surgery, Rambam Medical Center, Haifa, IsraelHaifa, Israel
Conclusion:Conclusion: low-dose aspirin should not be stopped low-dose aspirin should not be stopped before oral surgerybefore oral surgery Journal of the American Dental Association 2000 131: Journal of the American Dental Association 2000 131:
1398, 1401-21398, 1401-2