Fits, Faints and Funny Turns Anne Grover CN1 Neurology.
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Transcript of Fits, Faints and Funny Turns Anne Grover CN1 Neurology.
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Fits, Faints and Funny Turns
Anne Grover
CN1 Neurology
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Objectives
To appreciate the wide range of disorders that present with ‘clinical events’
To discuss epileptic ‘lookalikes’To outline history taking
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Seizures
Are characterized by a sudden change in movement, behaviour, sensation or consciousness produced by a sudden burst of excessive electrical activity in brain cells causing a chemical (neurotransmitter) imbalance.
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Causes of seizures
Brain Tumour
Medications
Drug/ alcoholabuse
Metabolic/ endocrine
Head injury
Stroke
Heart diseaseHigh BP
Fever
Brain infection
Seizures
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Epilepsy
Epilepsy – refers to a group of different neurological conditions characterised by recurrent, unprovoked epileptic seizures
A manifestation(s) of epileptic excessive usually self-limiting activity of neurons in the brain
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Epilepsy
Affects 1 in 115 peoplePrevalence in Ireland <42 000 people with
epilepsy Approximately 50 million worldwideOne of the most common serious chronic
neurological conditions
1. Joint Epilepsy Council. Epilepsy prevalence, incidence and other statistics. 2011; 2. Brainwave 2009
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FocalFocal dischargesSome loss of awareness
GeneralisedDischarges coming from both hemispheresComplete loss of consciousness
‘Aura’ Motor/sensoryChange in awareness and behaviour
Secondary generalisedUsually tonic clonic convulsion
Absence‘Blank spell’
Myoclonic jerk Twitch/jerk
TonicStiffness
AtonicDrop attack
Tonic clonicConvulsion
SEIZURE CLASSIFICATIONSEIZURE CLASSIFICATION
INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010
IE/BUC/12/0304
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Electroclinical syndromes
Defined as an ‘electroclinical’ pattern of clinical features and investigation findings may have different aetiologies.
Common electroclinical syndromes eg- Childhood absence epilepsy - Juvenile absence epilepsy - Juvenile myoclonic epilepsy - Lennox Gastaut
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Generalised Tonic Clonic Seizure
Prodromes – non-epileptic clinical alteration prior to onset of an epileptic seizure
Aura – “warning sign” – epileptic seizure experienced prior to GTCS
Initial tonic phase -Epileptic cry, eyes open, roll upwards, jaw clamps shut Limbs stiff & extended, arms may flex, cyanosis
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Clonic Phase
Rhythmic jerking of all 4 limbs, jaw & facial muscles
May froth at the mouth, bite tongue, urinary incontinence
Jerking gradually slows before stopping
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Itcal phase
Followed by flaccidity of musclesConsciousness slowly regained, may
lapse into deep sleep minutes to hours after
GTCS generally self-limiting, last 1-2 minutes
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ACTION
A Assess the situation, ABC’s. Get assistance.
Remove any object that could cause harm
C Cushion patient’s head to protect from injury
T Time, note the time the seizure started
I Identify possible cause
O Over, put patient into recovery position when
possible, note what happened, time seizure ended.
N Never restrain the patient, or put
anything into their mouth.
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Provoking factors
Illness or feverSleep deprivationMissing doses AED’sAlcoholStress
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Prolonged acute epileptic seizures
Definition of status epilepticus:A seizure lasting >5 minutes, orTwo or more seizures without a return of
consciousness between seizures1
Immediate treatment is recommended for:Prolonged seizures ≥5 minutes, orRepeated convulsive seizures (≥3 in an hour)2
Treatment delay lessens the chance of successful response to a single medication3
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Women’s issues
Menstrual cycleFertilityContraceptionPregnancy
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Lifestyle implications
• Social issues
• Driving
• Working
• Personal safety
• Good nutrition, special diets
• Memory problems
• Mood changes
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Syncope Psychogenic non-epileptic seizures (PNES)Transient ischaemic attackNarcolepsy/cataplexy/sleep apneaSleep-walking, night terrorsPanic attackComplex migraines.Cardiac arrhythmias.
Seizure imitators
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Syncope
LOC & postural toneBrief stiffening or spasms & irregular jerks of the
limbsEyes open, roll upwardsUrinary incontinence & traumaGenerally less than 10 secondsConvulsive syncope - 70-90%
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Psychogenic non-epileptic seizures
Appear to lose consciousness & fallEyes closedOften lack stereotypical characteristicsJerking may be asymmetric,
asynchronous, wax and wanePelvic thrust, flailing & tremorsVocalise throughoutConsciousness may be retained
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GTCS Syncope PNES
J erking of limbs Rhythmical, symmetrical & synchronous
Arrhythmical, asymmetric
Wax and wane, side to side movements& hip thrusting
Duration of event 1-2 minutes 1-30 seconds Often longer
Eyes Open & roll upwards
Open & roll upwards
Often closed
Urinary incontinence & tongue biting
May occur May occur May occur
EEG Abnormal Generalised slowing
Normal awake rhythm
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Diagnosis
History
History
History
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History
Obtain a detailed account of the event from the patient and a witness
Where, when, what happened?Any warning sign? Any triggers? First event? Other events?Progression- How did it start?After the event?Useful features
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Conclusion
Epilepsy is one of the most serious, chronic neurological conditions
Can be difficult to distinguish between imitators
20-30% of patients misdiagnosedA detailed history can assist with
diagnosis
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References
Brainwave The Irish Epilepsy Association. Shedding Light on Epilepsy. A nurses information pack.
Epilepsy Ireland. (2009).The prevalence of Epilepsy in Ireland Study. www.epilepsy.ie Murphy, S., Epilepsy-definitions, diagnosis and treatment. Nursing in General Practice. Nizam, S., Spencer, S.S. (2004). An approach to the evaluation of a patient for seizures
and epilepsy. Wisconsin Medical Journal. 103:1. British Paediatric Neurology Association. (2013). Paediatric Epilepsy Training Level One
Handbook. United Kingdom.
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Thank you