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What is the first-line medication recommended for a patient experiencing seizures?
What is the first-line medication recommended for a patient experiencing seizures?
What is the maximum dose of IV Lorazepam that can be administered for a patient during a seizure?
What is the maximum dose of IV Lorazepam that can be administered for a patient during a seizure?
If IV access is not available, which alternative medication can be considered for seizure management?
If IV access is not available, which alternative medication can be considered for seizure management?
During the initial management of a seizure, what is an important step to take besides medication?
During the initial management of a seizure, what is an important step to take besides medication?
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What should be done first when a patient is seizing for the first time?
What should be done first when a patient is seizing for the first time?
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Which genetic mutation is associated with Dravet syndrome?
Which genetic mutation is associated with Dravet syndrome?
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What is a common cause of acute symptomatic seizures?
What is a common cause of acute symptomatic seizures?
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Which of the following factors is NOT typically recognized as a seizure trigger?
Which of the following factors is NOT typically recognized as a seizure trigger?
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How do acute seizures generally differ from epilepsy in terms of causation?
How do acute seizures generally differ from epilepsy in terms of causation?
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What is one way that hypoxia can contribute to the development of epilepsy?
What is one way that hypoxia can contribute to the development of epilepsy?
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Which syndrome is associated with autosomal dominant epilepsy with auditory features?
Which syndrome is associated with autosomal dominant epilepsy with auditory features?
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What risk factor is commonly linked to increased seizures in individuals with epilepsy?
What risk factor is commonly linked to increased seizures in individuals with epilepsy?
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Which of the following correctly describes the characteristics of the neurons in the epileptogenic focus?
Which of the following correctly describes the characteristics of the neurons in the epileptogenic focus?
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What step should be taken if a patient is still seizing after 10 minutes?
What step should be taken if a patient is still seizing after 10 minutes?
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When should chronic treatment with anti-epileptic drugs be initiated?
When should chronic treatment with anti-epileptic drugs be initiated?
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Which condition does NOT warrant the start of chronic anti-epileptic medication after a first seizure?
Which condition does NOT warrant the start of chronic anti-epileptic medication after a first seizure?
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What should patients be educated about regarding their medications?
What should patients be educated about regarding their medications?
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What specific activity should patients be counseled about to avoid danger due to potential sudden loss of consciousness?
What specific activity should patients be counseled about to avoid danger due to potential sudden loss of consciousness?
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What is the initial intravenous dose of Magnesium Sulphate for treatment?
What is the initial intravenous dose of Magnesium Sulphate for treatment?
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What is the maximum dose of Lorazepam per administration?
What is the maximum dose of Lorazepam per administration?
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What alternative administration route is recommended for midazolam if IV access is unavailable?
What alternative administration route is recommended for midazolam if IV access is unavailable?
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What is the maximum infusion rate for Phenytoin?
What is the maximum infusion rate for Phenytoin?
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What should be done if the patient continues to experience seizures after the second therapy phase?
What should be done if the patient continues to experience seizures after the second therapy phase?
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Which of the following is an alternative option for second line therapy for ongoing seizures?
Which of the following is an alternative option for second line therapy for ongoing seizures?
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What is the recommended volume of Normal Saline for a Phenytoin dose greater than 1g?
What is the recommended volume of Normal Saline for a Phenytoin dose greater than 1g?
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How should Levetiracetam be infused?
How should Levetiracetam be infused?
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What is the minimum seizure-free period required for Group 1 drivers in Ireland after a first unprovoked seizure?
What is the minimum seizure-free period required for Group 1 drivers in Ireland after a first unprovoked seizure?
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What is the primary goal in the treatment of epilepsy?
What is the primary goal in the treatment of epilepsy?
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Which of the following may benefit from epilepsy surgery?
Which of the following may benefit from epilepsy surgery?
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What type of epilepsy is characterized by stiffness and nighttime incontinence in a 45-year-old with intellectual disability?
What type of epilepsy is characterized by stiffness and nighttime incontinence in a 45-year-old with intellectual disability?
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Which co-morbidity is mentioned for a 29-year-old with focal epilepsy and memory issues?
Which co-morbidity is mentioned for a 29-year-old with focal epilepsy and memory issues?
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What is one consideration when treating epilepsy in women of childbearing age?
What is one consideration when treating epilepsy in women of childbearing age?
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Which of these would be indicated for epilepsy with a clearly defined focus?
Which of these would be indicated for epilepsy with a clearly defined focus?
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At what age is a 6-year-old child indicated for treatment of typical absence seizures?
At what age is a 6-year-old child indicated for treatment of typical absence seizures?
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Which factor is NOT typically considered when treating a patient with epilepsy?
Which factor is NOT typically considered when treating a patient with epilepsy?
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What is one future development in the treatment of epilepsy mentioned?
What is one future development in the treatment of epilepsy mentioned?
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Which genetic mutation is primarily associated with autosomal dominant nocturnal frontal lobe epilepsy?
Which genetic mutation is primarily associated with autosomal dominant nocturnal frontal lobe epilepsy?
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What best defines epilepsy?
What best defines epilepsy?
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What factor is NOT recognized as a common seizure trigger?
What factor is NOT recognized as a common seizure trigger?
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Which of the following types of seizure onset indicates bilateral brain involvement?
Which of the following types of seizure onset indicates bilateral brain involvement?
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Which of these is a cause of unprovoked seizures leading to epilepsy?
Which of these is a cause of unprovoked seizures leading to epilepsy?
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Which statement about provoked seizures is accurate?
Which statement about provoked seizures is accurate?
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What is commonly considered a potential outcome of hypoxia related to seizure activity?
What is commonly considered a potential outcome of hypoxia related to seizure activity?
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Which of the following is most likely to contribute to the hyperexcitation of neurons in the epileptogenic focus?
Which of the following is most likely to contribute to the hyperexcitation of neurons in the epileptogenic focus?
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How is awareness classified in seizure types?
How is awareness classified in seizure types?
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What describes the typical characteristic of neurons within the epileptogenic focus?
What describes the typical characteristic of neurons within the epileptogenic focus?
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Which of the following correctly describes unprovoked seizures?
Which of the following correctly describes unprovoked seizures?
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What is a common feature of remote symptomatic seizures?
What is a common feature of remote symptomatic seizures?
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Which syndrome is associated with various de novo mutations including DNM1?
Which syndrome is associated with various de novo mutations including DNM1?
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Which of the following factors is considered a direct cause of acute symptomatic seizures?
Which of the following factors is considered a direct cause of acute symptomatic seizures?
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What does the term 'cerebral cortex' refer to in relation to epilepsy?
What does the term 'cerebral cortex' refer to in relation to epilepsy?
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Which of the following is NOT a typical characteristic of epilepsy as a disorder?
Which of the following is NOT a typical characteristic of epilepsy as a disorder?
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What is the gold standard for confirming a diagnosis of epilepsy?
What is the gold standard for confirming a diagnosis of epilepsy?
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Which medication is first-line for the emergency management of a seizure lasting more than five minutes?
Which medication is first-line for the emergency management of a seizure lasting more than five minutes?
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If a patient is suspected to have meningitis, which procedure is essential to perform before a lumbar puncture (LP)?
If a patient is suspected to have meningitis, which procedure is essential to perform before a lumbar puncture (LP)?
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Which factor is critical in the management of a patient in status epilepticus?
Which factor is critical in the management of a patient in status epilepticus?
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What is a potential result of a normal EEG following a patient's first seizure?
What is a potential result of a normal EEG following a patient's first seizure?
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During which testing phase can sleep deprivation be used for increased yield in EEG results?
During which testing phase can sleep deprivation be used for increased yield in EEG results?
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In what situation is MRI considered more sensitive than CT imaging?
In what situation is MRI considered more sensitive than CT imaging?
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Which condition may progress to seizures if not treated appropriately during pregnancy?
Which condition may progress to seizures if not treated appropriately during pregnancy?
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What is the maintenance dose of Magnesium Sulphate after the initial intravenous administration?
What is the maintenance dose of Magnesium Sulphate after the initial intravenous administration?
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Which option represents the correct administration route for midazolam for patients weighing less than 40kg if IV access is not available?
Which option represents the correct administration route for midazolam for patients weighing less than 40kg if IV access is not available?
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What is the maximum dose of IV Levetiracetam that can be administered during the second therapy phase?
What is the maximum dose of IV Levetiracetam that can be administered during the second therapy phase?
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What is the minimum infusion rate for Phenytoin during the second therapy phase?
What is the minimum infusion rate for Phenytoin during the second therapy phase?
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If a patient continues seizing after administering the secondary therapies, which specialty should be contacted?
If a patient continues seizing after administering the secondary therapies, which specialty should be contacted?
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For a seizure requiring Levetiracetam infusion, what is the recommended volume of Normal Saline for an infusion of 1 g?
For a seizure requiring Levetiracetam infusion, what is the recommended volume of Normal Saline for an infusion of 1 g?
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What is the maximum dose of IV sodium valproate that can be administered during the second therapy phase?
What is the maximum dose of IV sodium valproate that can be administered during the second therapy phase?
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What is the correct administration time for Levetiracetam IV infusion?
What is the correct administration time for Levetiracetam IV infusion?
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What is a significant reason for starting chronic treatment with anti-epileptic drugs after a single seizure?
What is a significant reason for starting chronic treatment with anti-epileptic drugs after a single seizure?
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Which intervention should be undertaken if a patient continues to seize after 20-60 minutes of therapy?
Which intervention should be undertaken if a patient continues to seize after 20-60 minutes of therapy?
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What critical aspect should be included in patient education regarding the management of seizures?
What critical aspect should be included in patient education regarding the management of seizures?
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Which of the following factors generally does NOT necessitate the start of chronic anti-epileptic medication after a single seizure?
Which of the following factors generally does NOT necessitate the start of chronic anti-epileptic medication after a single seizure?
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What should be indicated for a patient after experiencing recurrent seizures if no immediate pharmacological intervention was effective?
What should be indicated for a patient after experiencing recurrent seizures if no immediate pharmacological intervention was effective?
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Study Notes
Epilepsy Syndromes
- Epilepsy syndromes are classified by age of onset, seizure type, EEG patterns, causes, and associated conditions.
- Many syndromes arise from specific gene mutations.
- Examples of epilepsy syndromes and their associated genes include:
- Autosomal dominant nocturnal frontal lobe epilepsy (NFLE) - CHRNA2 gene
- Autosomal dominant epilepsy with auditory features - LGI1 gene
- Juvenile myoclonic Epilepsy - Complex gene mutations
- Childhood Absence Epilepsy - Complex gene mutations
- Dravet syndrome - SCN1A gene
- Lennox-Gastaut syndrome - Various de novo mutations, including DNM1 and SLC6A1 genes
Epilepsy Causes and Risk Factors
-
Acute symptomatic seizures (provoked seizures):
- Acute hemorrhagic and ischemic stroke
- Metabolic encephalopathy
- Drugs and alcohol
- Other factors like head trauma, active intracranial infections
-
Epilepsy (unprovoked seizures):
- Cerebrovascular disease (stroke, vascular malformations)
- Dementia
- Brain tumors, remote head trauma, prior intracranial infections
- Unknown causes: A significant portion of epilepsy cases have undetermined causes.
Seizure Triggers and Risk Factors
- Lack of sleep
- Alcohol abuse
- Medications: missed doses, new medications causing interactions with anti-seizure medications (ASMs)
- Stress
- Acute illnesses and fever
- Dehydration
- Head injury
- Stroke
- Flashing lights (photosensitive epilepsy occurs in 3-5% of all epilepsy cases)
- Loud noise or music (reflex epilepsy)
Epilepsy Pathophysiology
- Seizures and epilepsy are caused by an imbalance between excitation and inhibition in the central nervous system.
- This imbalance arises from hyperexcitation and hypersynchronization of neuronal networks.
- Hypoxia, alkalosis, hypoglycemia, and abnormal neurotransmitter properties contribute to this imbalance, leading to seizure activity.
Epilepsy Management
- First-line treatment: Benzodiazepines (diazepam, midazolam, lorazepam)
- Second-line treatment: Levetiracetam or phenytoin
- Third-line treatment: Midazolam, propofol, or barbiturate agents
- Non-convulsive status epilepticus: Commonly seen in critically ill patients in the ICU
-
Chronic Treatment with Anti-epileptic Drugs (AEDs):
- Usually not necessary after a single seizure, especially if provoked by resolved factors.
- Started in patients with a high risk of recurrent seizures.
- Generally started after two or more unprovoked seizures.
- May be started after one seizure if:
- Epileptiform abnormalities on EEG
- Remote symptomatic cause of epilepsy
- Abnormal neurological examination
- First seizure during sleep
-
Patient Education:
- Side effects of medications
- Management of triggers (sleep hygiene, alcohol, medication compliance)
- Counseling regarding unsupervised activities that could pose danger with sudden loss of consciousness (working at heights, machinery, hot surfaces, swimming alone)
- Information on SUDEP (sudden unexplained death in epilepsy)
- Driving restrictions:
- Group 1 drivers (car, motorcycle, tractor) must stop driving for one year after a seizure.
- After one unprovoked seizure, Group 1 drivers must be seizure-free for six months before driving and must undergo a medical evaluation to determine fitness to drive.
-
Treatment Approaches:
- Ideally, one drug appropriate to the diagnosis should be used.
- About two-thirds of new epilepsy diagnoses are successfully controlled with the first AED.
- Goal is to achieve seizure-free status without adverse side effects.
- Treatment considerations include:
- Interactions with other medications
- Co-morbid medical conditions (renal, hepatic disease)
- Age of the patient
- Women of childbearing age/pregnancy
- Lifestyle and patient preferences
- Cost
-
Other Treatment Options:
- Epilepsy surgery: Considered for patients with poorly controlled seizures. Requires a clearly defined seizure focus. Especially helpful for seizures from structural abnormalities. Can potentially cure some forms of epilepsy.
- Vagal nerve stimulation/Devices: Implanted device that sends regular electrical pulses to the vagus nerve, helping to regulate brain activity and prevent seizures.
- Dietary therapies: Ketogenic diet is a high-fat, low-carbohydrate diet that can help control seizures in some individuals.
Future Developments in Epilepsy Treatment and Management
- Newer AEDs
- Parenteral formulations
- Direct comparison trials
- Cost considerations
- Pharmacogenetics (personalized treatment based on individual genetic makeup)
- Laser surgery
- Neurostimulation
- Precision medicine
Common Epilepsy Syndromes
-
Case 1: 16-year-old with morning jerks, daydreaming spells, and generalized tonic-clonic seizures (GTC) after alcohol consumption.
- Epilepsy type: Generalized
- Seizure types: Myoclonic, Absence, GTC
- Cause: Genetic
- Co-morbidity: Migraine
-
Case 2: 29-year-old with febrile seizures as an infant, déjà vu and fear auras, and GTC seizures from sleep.
- Epilepsy type: Focal
- Seizure types: Psychic aura, automatism, GTC
- Cause: Mesial temporal sclerosis
- Co-morbidities: Memory loss, depression
-
Case 3: 45-year-old with intellectual disability, autism, nocturnal stiffening episodes, and other episodes of unawareness, restlessness, and agitation.
- Epilepsy type: Generalized and Focal
- Seizure types: Generalized tonic, atypical absence, atonic seizures
- Cause: Unknown, DNM1 gene mutation
- Co-morbidities: Intellectual disability (ID)
-
Case 4: 6-year-old with episodes of zoning out, difficulty keeping up in school, and eye fluttering/activity arrest.
- Epilepsy type: Generalized
- Seizure types: Typical absence
- Cause: Genetic
- Co-morbilities: ADHD
-
Case 5: 78-year-old with a left frontal stroke 18 months ago. Experiences right arm jerking and confusion.
- Epilepsy type: Focal
- Seizure type: Right arm clonic seizure
- Cause: Post-stroke epilepsy
- Co-morbidities: Right hemiparesis
What is Epilepsy?
- Epilepsy is a disorder of the central nervous system (CNS) characterized by recurrent seizures.
- Seizures are caused by excessive electrical discharge from the cerebral cortex.
- The International League Against Epilepsy (ILAE) defines epilepsy as at least two unprovoked seizures, or one seizure with electrographic (EEG) evidence of epileptiform activity.
- Epilepsy affects approximately 1% of the population worldwide.
- Epilepsy is a heterogeneous disorder with variable causes, seizure types, syndromes, and prognoses.
Types of Epilepsy
- Epilepsy can have either focal or generalized onset.
- Focal onset seizures begin in a specific area of the brain.
- Generalized onset seizures involve both sides of the brain.
- Unknown onset seizures have unclear origins.
- Awareness level during a seizure determines if the individual is aware of their surroundings.
- Motor or non-motor describes whether movement is involved in a seizure.
Causes of Epilepsy
-
Acute symptomatic seizures (provoked seizures) can be triggered by:
- Acute hemorrhagic and ischemic stroke
- Metabolic encephalopathy
- Drug and alcohol intoxication/withdrawal
- Recent head trauma
- Active intracranial infections
-
Epilepsy (unprovoked seizures) can be caused by:
- Cerebrovascular disease
- Dementia
- Brain tumors
- Remote head trauma
- Prior intracranial infection
- Unknown causes are also common.
Seizure Triggers and Risk Factors
- Lack of sleep
- Alcohol abuse
- Missed doses or starting a new medication that interacts with anti-seizure medication (ASM)
- Stress
- Acute illnesses and fever
- Dehydration
- Head injury
- Stroke
- Flashing lights (photosensitive epilepsy)
- Loud noise or music (reflex epilepsy)
Chronic Treatment with Anti-Epileptic Drugs
- Anti-epileptic drugs (AEDs) are usually not necessary after a single seizure, especially if provoked by factors that resolve.
- AEDs are typically prescribed after:
- Two or more unprovoked seizures
- One seizure with:
- Epileptiform abnormalities on EEG
- A remote symptomatic cause (e.g., brain tumor, brain malformation)
- Abnormal neurologic examination
- A first seizure that occurs during sleep
Management of Epilepsy
-
Investigations
- Neuroimaging: Non-contrast CT Brain followed by MRI brain
- EEG: Used to support the diagnosis of epilepsy, but a normal EEG does not exclude epilepsy.
- LP: Suspected intracranial infection or inflammatory disease
- Metabolic/Genetic studies: Help determine potential causes and guide treatment.
-
Patient Education:
- Side effects of medication
- Management of triggers (e.g., sleep hygiene, alcohol)
- Counseling about activities that might pose danger with sudden loss of consciousness.
Status Epilepticus
- Prolonged seizure lasting over 5 minutes, or a series of seizures with incomplete recovery of consciousness.
- A medical emergency requiring immediate intervention.
- May be caused by acute symptomatic (metabolic/structural) factors.
- Emergency management includes:
- 1st Line: Benzodiazepines (diazepam PR, midazolam buccal, lorazepam IV)
- 2nd Line: Levetiracetam IV, phenytoin IV, valproate IV
- 3rd Line: Phenobarbital and propofol infusion, general anesthesia
Support for Status Epilepticus
- Maintain the patient's airway, breathing, and circulation (ABCs).
- Provide oxygen via a non-rebreather mask.
- Position the patient on their left side to reduce the risk of aspiration.
Management of Status Epilepticus: Step-by-Step Guide
- Initial Phase: Give IV Magnesium Sulfate (4g over 5-15 min, followed by 1g/hr for 24 hours). Repeat IV Lorazepam (0.1mg/kg; max 4mg). If no IV access, give IM midazolam (10mg; 5mg for patients under 40kg and elderly).
- Second Phase: Give Levetiracetam IV (60mg/kg; max 4.5g) or Phenytoin IV (20mg/kg; max 2g).
- Third Phase: If seizures continue, contact ICU/anesthesia for infusion of midazolam, propofol, or barbiturate agents.
Key Terms
- Provoked seizure: Seizure caused by a known trigger.
- Unprovoked seizure: Seizure with no identifiable cause.
- Remote symptomatic seizure: Seizure associated with a previous brain injury or disorder.
- Onset: Point in the brain where the seizure originates.
- Awareness level: Whether the individual is conscious during a seizure.
- Motor or non-motor: Whether movement occurs during a seizure.
- Electroencephalography (EEG): A test that records electrical activity in the brain.
- Anti-seizure medication (ASM): Medication used to prevent or reduce seizures.
- Status epilepticus: A medical emergency characterized by a prolonged seizure or continuous series of seizures.
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Description
This quiz covers various epilepsy syndromes, their genetic causes, and risk factors associated with seizures. Explore the classification of epilepsy based on age, seizure type, and EEG patterns, along with examples of syndromes and their related genes. Test your knowledge on acute and unprovoked seizures.
