1. Another talk about blackouts.
YES!
Another talk about blackouts.

2. BECAUSE: IT IS COMMON IT IS BADLY MANAGED IT CAN RUIN LIVES
IT IS INTERESTING
YOU CAN DO A LOT

3. plan Recognition & investigation Safety Advice Old & New drugs
pregnancy
Status epilepticus

4. 6/100 WILL HAVE ONE SEIZURE
3/100 WILL HAVE TWO OR MORE
2-3X GREATER MORTALITY
PSYCHOSOCIAL HANDICAP
20-30% “intractable” epilepsy is NOT
~50% of “status” is psychogenic
SOME NASTY THINGS CAUSE SEIZURES
SOME EPILEPSIES ARE INHERITED
Some epilepsy can be cured – surgery!
“BLACKOUT ?CAUSE”………….

6. Hughlings – Jackson (1870)
born Green Hammerton Nr York.
A convulsion is but a symptom, and implies only….
A disorderly discharge of nerve tissue on muscles.
It occurs with all sorts of conditions of ill health,
At all ages, and under innumerable circumstances.

7. Seizures are: SUDDEN. SHORT STEREOTYPED. Tongue biting
Clustering, associations
Where do they wake up?

9. POSITIVE SYMPTOMS usually A SEIZURE.
NEGATIVE SYMPTOMS usually FOCAL ISCHAEMIA.
MIGRAINE OFTEN A MIXTURE, + “MARCH”
Multiple & stereotyped attacks RARE in TIA, (?monocular vision)
In epilepsy & migraine pattern of spread NOT vascular territry.
Altered awareness much more common in seizure & psychogenic
Diplopia not seizure, Deja vue not vascular.

10. video

11. When in doubt? GET A WITNESS (home video). The diagnosis is clinical.
WAIT AND SEE. More harm-if false positive.
The EEG does NOT diagnose epilepsy.
Video-telemetry can be useful.

13. classification
Most epilepsy presenting >20years is of focal onset or acute symptomatic eg alcohol
Childhood “idiopathic” ep. Is characterised by well defined electroclinical syndromes.

14. classification Primary generalised Partial simple complex
Secondary generalisation

15. classification Childhood absence (3-10) female Juvenile absence (7-16)
Juvenile myoclonic
Ep with T-C on waking
Benign with Rolandic spikes
Benign occipital

16. Differential diagnosis
Reflex syncope, posture etc
Cardiac syncope, rhythm, valves etc
Perfusion failure, hypovolaemia, autonomic failure.
Psychogenic, NEA, Panic, breath holding.
Migraine
TIA
Narcolepsy/cataplexy.
Hypoglycaemia.

17. treatment ONE DRUG START LOW – GO SLOW TOXICITY TERATOGENICITY
INFORMATION

18. treatment Carbamazepine Valproate Lamotrigine Gabapentin Tiagabine
Topiramate
levetiracetam

19. Chronic toxicity
Memory/cognitive, behaviour, cerebellar atrophy, neuropathy
Retinopathy
Acne, hairy, alopecia, chloasma
Liver enzyme induction
IgA deficiency, SLE
Megaloblastic, thrombocytopaenia

20. chronic toxicity
Decreased thyroxine, increased cortisol/sex hormone metabolism
Osteomalacia
Gum hypertrophy, coarse features, Dupuytrens.

21. safety advice DVLA: THE LAW! Pilots, ships captains.
Swimming, climbing, hang gliding, scuba diving.
Machines? (unwarranted job discrimination)
Too much restriction is usual.
Sleep deprivation
alcohol

22. Pregnancy:
Advise in advance.
Risk from uncontrolled seizures > teratogenicity.
Lowest dose, single drug, avoid valproate.
Folic acid 5mg daily, min 3/12 before trying.
UK pregnancy register, RVH Belfast.

23. teratogenicity
0.5% all pregnancies
Monot 4-6%
Two %
More %

24. status A-B-C, glucose, thiamine. Look for a cause?
Alcohol, stroke, tumour, infection…
Drug withdrawal
Psychogenic NEAD.

25. Convulsive status epilepticus: Adult treatment protocol
Brief Management Overview
(see Detailed Management Outline for more information)
Oxygen
GIVE glucose if BM is low
(50ml of glucose 50% solution IV)
(50% not suitable for children)
GIVE thiamine if alcohol abuse suspected
(10ml of Pabrinex IV over 10 minutes)
Lorazepam 4mg IV
If seizures persist after 10 minutes
Consider:
Pseudostatus/Non Epileptic attacks
FOSPHENYTOIN DOSE 15mg phenytoin equivalent (PE) per kg IV
(See Detailed Management Outline for administration details)
If seizures persist after 20minutes:
Transfer to ICU
Paraldehyde
Phenobarbitone (on ICU)
General anaesthesia with Thiopentone or Propofol
FOSPHENYTOIN 750mg = 500mg PHENYTOIN EQUIVALENTS (PE)
NB: THIS DOCUMENT ONLY APPLIES TO ADULTS SEE SEPARATE DOCUMENT FOR TREATMENT OF STATUS EPILEPTICUS IN CHILDREN

26. information British Ep Assoc. www.epilepsy.org.uk
The National Soc for Ep.
DVLA:
Smith & Wallace, “A clinicians guide to epilepsy.” Arnold 2001