Epilepsy and Spells
A chronic disorder of the cerebral cortex characterized by recurrent, unprovoked seizures.
An alteration of consciousness, sensation, and/or behavior caused by a hypersynchronous discharge in the cerebral cortex.
TYPES OF EPILEPSY:
TYPES OF SEIZURES:
1. simple partial (no alteration of consciousness) auras are simple partial seizures.
2. complex partial seizures (alteration but not complete loss of consciousness)
3. generalized seizures (tonic-clonic, absence, myoclonic, tonic, atonic)
A partial or generalized seizure lasting more than 20 minutes or recurrent seizures without full recovery of consciousness. Practically, any seizure lasting more than five minutes should be treated as status.
MANAGEMENT OF PATIENTS WITH EPILEPSY:
1. lorazepam 0.1mg/Kg IV
2. fosphenytoin 20 pe/Kg IV
3. repeat fosphenytoin 10 pe/Kg IV
5. phenobarbital 20 mg/Kg IV, then repeat 10 mg/Kg IV
pentobarbital 5 mg/Kg IV, then 1.5 mg/Kg/hr and titrate up
midazolam 0.2 mg/Kg IV, then 0.1 mg/Kg/hr and titrate up
propofol 2 mg/Kg IV, then 1 mg/Kg/hr and titrate up
valproate 25 mg/Kg IV, then repeat 25mg 1Kg
- phenobarbital - effective, narrow-spectrum, and cheap, but lots of side effects.
- phenytoin (Dilantin)-effective, narrow-spectrum, generic is relatively cheap, causes gingival hyperplasia and hirsutism.
- carbamazepine (Tegretol)-effective, narrow spectrum, generic moderately priced, caused leukopenia, SIADH in the elderly.
- valproate (Depakote)-effective, broad-spectrum, generic is cheap, trade name is moderately expensive, causes hair loss, weight gain, tremor, and polycystic ovary disease.
- gabapentin (Neurontin)-effective (may need high doses), narrow spectrum, moderately expensive, causes fewer side effects, cleared by the kidney.
- Lamotrigine (Lamictal)-effective, broad-spectrum, expensive, Steven-Johnson Syndrome must increase dose very slowly.
- topiramate (Topamax)-effective, broad-spectrum, expensive, may have more severe cognitive slowing.
- tiagabine (Gabatril)-effective, narrow-spectrum, expensive, may have less side effects.
- levetiracetam (Keppra)-effective, broad spectrum, expensive, unique mechanism of action (unknown), less side effects.
- zonisamide (zonegran)-effective, broad spectrum, expensive, kidney stones.
- oxcarbazepine (Trileptal) - effective, narrow spectrum, expensive, good side-effect profile
2. Vagus Nerve Stimulator - effective, narrow spectrum, expensive, requires surgical implantation, no cognitive side effects.
3. Epilepsy Surgery - very effective, only "cure" for epilepsy, extremely expensive, potential surgical morbidity and mortality. Requires in-patient monitoring, sometimes including invasive monitoring.
Physiologic - see dizziness and syncope handout.
Psychogenic-15% of outpatients, 30% patients hospitalized for video/telemetry, and 50% of patients in status epilepticus have pseudo-seizures.
Pseudo-seizure red flags: no response to anti-convulsants, very prolonged seizures, and history of prior conversion symptoms.
Video/EEG telemetry monitoring best makes diagnosis.
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