Seizure ii
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Transcript of Seizure ii
DIAGNOSIS :
HISTORY : Description about seizure activity.• Age of Onset.
• Duration.
• Focal / Generalized.
• Loss of conciousness, associated features .
• H/o previous attack.
• H/O Trauma, Drug ingestion.
• Meningitis , encephalitis.• Precipitating factor (fever, viral illness, diarrhoea).• Frequency.• Time of day –early morning ,in drowsy state childhood
epilepsy.
• Detail treatment hist, response to treatment.
• Prolonged personality change or intellectual deterioration, regression of milestone –neurogenerative disorder.
• Family history.• Developmental history.
PHYSICAL EXAMINATION :
• Head Cicumference & Fontanale.
• Facial abnormality.
• Sign of degenerative, Metabolic and Congenital disease.
• Hepatosplenomegaly –storage disease.
• Neurocutaneous marker. Skin rash –Meningitis, Sepsis.
• CVS— H.R , BP , Peripheral perfusion.
• RESPIRATORY : Cyanosis, Irregular breathing.
• CNS :• Pupil . Fundus --Papilledema.
• Cranial Nerves.
• Sign of meningeal irritation.↑ ICP.
• Sensory , Motor system examination.
INVESTIGATIONS :
EEG : Support diagnosis. Confirm diagnosis. Classification type. Locate the epileptic focus.
• A normal EEG does not R/o epilepsy.• Abnormal EEG always not indicates Epilepsy.
• If standard EEG normal --• sleep/ sleep deprived EEG.• 24 hrs Ambulatory EEG. • Vediotelemetry.
EEGIt is a record of the underlying neuronal activity of brain.
• What are normal brain waves?
• β wave (fast ) >13Hz/sec --alert state.• α wave (intermediate) 8—13Hz/sec –quite
awareness.• Theta wave (slow) 4—7 Hz/sec –drowsiness.• δ wave (slower) <4Hz/sec –deep sleep.
• α Activity seen is normally seen in children.
BLOOD EXAMINATION :
• Serum electrolytes.
• Serum Ca+ , Mg +. Blood sugar.
• CBC, Septic work up Including LP.
• RFT , LFT.
• Toxicological screening.
OTHERS : CT / USG/ MRI.
DIFFERENTIAL DIAGNOSIS :
1.BREATH HOLDING SPELL :
• Age group — 6month — 2years. - rarely upto 5 years.
• Precipitated by Fear , Frustration , Anger & Anxeity.
• Cry vigorously holds breath apnea cyanosis LOC Convulsion.
• But in seizure , convulsion cyanosis.
2.REFLEX ANOXIC SEIZURE:
• Age group : Toddler.
• Precipitated by : Pain, Discomfort, Fright, cold food , Head trauma.
• Severe pain stop breathing Hypoxia Pale convulsion rapid recovery.
• This episode occurs due to cardiac asystole from vagal inhibition.
3.SYNCOPE :
• Preceeds by pallor , Nausia , Vomiting , Sweating , Blurring of vision ,Hypotension.
• POSITION : Prolonged standing.
• Precipitating Factor : Emotional upset , Pain , Anxiety.
• Duration : few min.
• Bradycardia , Hypotension, Clonic convulsion.
• H/o heart disease .
4.MIGRAINE :
• Paroxysmal headache.
• Unsteadiness or Light headedness.
• Visual or Gastro intestinal disturbance.
5.BENIGN PAROXYSMAL VERTIGO :
• Recurrent attack of vertigo lasting for several minutes.
• Nystagmus.
• Unsteadiness or even Falling.
• Occurs as a result of Viral Labyrinthitis.
6.CARDIAC ARRYTHMIA :
• Prolonged Q T Interval may some time cause
Collapse or Cardiac Syncope.
• Usually occurs after Exercise.
7. NIGHT TERROR.
8.NON EPILEPTIC ATTACK DISORDER:( NEAD)
1. Pseudoseizure.
2. Fabricated illness.– fabricated by parents.
3. Induced illness.- Induced by hypoglycemia or Insulin over dose.
• PSEUDOSEIZURE :
• Incidence –5—10 %.
• Female.
• Age – 10—12yr.
• Unresponsive to AED.
• Precipitating factor –Emotional upset.
• Tendency to occur in company.
• Never occur when the patient is alone.
• Poor psychosocial history.
TREATMENT :
• Confirm diagnosis before starting treatment.• Explain to the parents about AED.
• Monotherapy at minimum dose should be attempted first.( the single most effective drug should be started)
• If not control by monotherapy switch to poly therapy.
• Drug level may be measured routinely.
• Anti epileptic therapy can usually be discontinued after 2 years
• Anti epileptic therapy can be discontinued after 2 years of Seizure free period over a period of 3—6 month.
• Indications of Polytherapy :
1. Worsening seizure.
2. Status epilepticus.
3. Non compliance.
4. Adverse effect.
SEIZURE TYPE 1st LINE 2ND LINE.
GENERALIZED:
- Sodium valproate. - Lamotrigine
1. Tonic clonic. - Carbamazepine.
2. Absence - Valproate. - Lamotrigine.
- Ethosuximide.
3. Myoclonic - Valproate. - Lamotrigine.
4. Infantile Spasm - ACTH. - Prednisolone
- Vigabatrine. - Valproate.
PARTIAL SEIZURE :
Simple partial - Carbamazepin Gabapentine.
& - Valproate.
Lamotrigine.
Complex partial
Topiramate.
DRUGS , DOSES & SIDE EFFECTS OF AED :
CARBAMAZEPINE : ( Tegretol)
DOSE : 10 mg / kg/ day.
- Increase upto 20—40 mg /kg /day B.D.
SIDE EFFECTS :
- Hepatotoxic .
- Bone Marrow depression ( Aplastic Anaemia ).
- Skin Rash.
PHENOBARBITONE (Luminal)
• DOSE :
- 15—20 mg/ kg loading dose .
- 5 mg/ kg/ day . B.d.
• SIDE EFFECTS :
- Drowsiness.
- Hyperkinesia.
- Drug dependency.
PHENYTOIN ( EPANOTIN)
• DOSE :
- 15—20 mg /kg loading dose . - 5mg/kg/day B.D.
• SIDE EFFECTS :
• Gingival hyperplasia.• Hirsutism.• Rickets. , Megaloblastic anaemia. Skin Rash ,
Nystagmus , Ataxia.
VALPROATE ( DEPAKINE )
• DOSE :
- 15—20mg/kg day stat.
- increase 5mg/week maximum
60mg/kg/day. BD ,TID , QID. • SIDE EFFECTS:
- Hepatic Necrosis.
- Pancreatitis.
- Weight gain.
- Hair loss.
ETHOSUXIMIDE (Zanotin)
• DOSE :
- 20—30 mg/kg/day B.D.
• SIDE EFFECTS :
- Nausia, Lethargy.
- Blood dyscrasias.
- SLE , Steven johnson Syndrome.
GABAPENTINE (Neurontin)
• DOSE :
- 30—60 mg/kg/day T. i. d.
• SIDE EFFECT: Nausia.
LAMOTRIGINE (lamictal)
• DOSE : 2mg/kg stat , 5—15mg/kg/day B.D.
• SIDE EFFECT: Skin rash.
TOPIRAMATE (Topamax )
• DOSE : - 1—9mg/kg/day BD.
• SIDE EFFECT : - Drowsiness. - Weight loss.
• VIGABATRINE (Sabril )
• DOSE : 50—150mg/kg/day. OD , BD.• SIDE EFFECT : Sedation , Restiction of visual field.