Epilepsy (and first seizure) on the acute take. Phil Smith Consultant Neurologist University Hospital of Wales, Cardiff

Transcription

1 Epilepsy (and first seizure) on the acute take Phil Smith Consultant Neurologist University Hospital of Wales, Cardiff

2 Epilepsy (and first seizure) on the acute take First suspected seizure Acute symptomatic seizure Resistant epilepsy

3 First suspected seizure causes Seizure Syncope Psychogenic ABC DEFG

4 Acute symptomatic seizure Acute encephalitis (viral or autoimmune) Venous sinus thrombosis Tumour Abscess (arterial stroke) Consider new onset of underlying cause

5 First suspected seizure History is crucial Focussed on diagnosis Often convulsive? previous Unexplained blackout is OK, but stratify risk

6 Reflex Syncope vs Seizure Syncope Seizure Trigger Common Rare Prodrome Almost always Common (aura) Onset Gradual Usually sudden Duration 1 30 seconds 1 3 minutes Colour Very pale Cyanosed Convulsions Common Common Incontinence Uncommon Common Lateral tongue bite Very rare Common Recovery Rapid Slow Injury Rare Common

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9 Investigations glucose ECG CT head First seizures need low tech approach

10 ECG ECG for all first seizures (and look at it)

11 A DIFFICULT CASE Pract Neurol 2010; 10: Life and death diagnosis David Chadwick, 1 Paddy Jelen, 2 Solomon Almond 3 The differential diagnosis of episodes of transient loss of consciousness can be straightforward but can also present some of the greatest diagnostic difficulties. In most circumstances, when there is uncertainty, usually when there have been only one or a few poorly observed events, it may be reasonable to admit to that uncertainty and await any further events to clarify the diagnosis. We have reason to know from bitter experience that this is not always the case and that more rigorous consideration of investigation may be justified rather than allowing the passage of time to clarify the diagnosis. INTRODUCTION Clinicians learn more from their mistakes than from any successes they might enjoy. This paper is intended to pass on the lessons learned from one such mistake. CASE REPORT Nina is seen in figure 1, aged 23 in 2005 on her graduation in architecture from Liverpool University. She was very proud to have studied at Liverpool. Her grandfather had studied 1 Emeritus Professor of Neurology, Walton Centre, Liverpool, UK 2 Nurse Practitioner, The Deepings Practice, Market Deeping, Peterborough, UK 3 Consultant in Acute Medicine, Royal Liverpool Hospital, Liverpool, UK Correspondence to D Chadwick, Walton Centre, Lower Lane, Liverpool L9 7LJ, UK; d.w.chadwick@liverpool.ac.uk Figure 1 Nina Jelen. PJ is East Midlands representative for Cardiac Risk in the Young

12 . Nina Jelen Aged 21 Oct 2003 boyfriend awoken erratic breathing, stiff, eyes open, unresponsive 2 3 min no convulsion, tongue bite or incontinence drowsy and amnesic for the event Emergency unit, assessed, referred, ECG normal First seizure clinic at 4 weeks: unexplained blackout Clinic review: normal MR brain and EEG probable epileptic seizure; review if needed

13 . Nina Jelen Aged 23 years, 2005 found at home dead, in bed

14 . Nina Jelen Family friend (a cardiologist) suggested cardiac investigations for three brothers see the emergency unit ECG

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17 Reflex vs cardiac syncope Reflex (vasovagal) Cardiac Older age Less common More common Trigger Common Uncommon Onset Gradual Sudden Nausea Common Uncommon Jerks None or brief None or brief Incontinence Uncommon Uncommon Lateral tongue bite Rare Occasional Duration 1 30 sec Variable Confusion after Rare Rare Fatigue Minutes to hours None

18 Unexplained blackouts: Risk stratification The event absence of vasovagal pointers (nausea, triggers) cardiogenic pointers (no warning, prompt recovery) Aged > 35 years evidence of structural heart disease (congestive heart failure, previous MI) abnormal ECG (especially previous MI) Aged < 35 years family history of sudden unexpected death < aged 35 years abnormal ECG (long QT, hypertrophy, septal T waves, WPW) Practical Neurology 2011; 11:

19 Urgent CT scan of head Slow to recover Focal signs Unusual features

20 Focal seizures May present as confusion

21 EEG Mainly for suspected non-convulsive status Rarely needed urgently

22 Epilepsy usually managed at home often brought against will Involve specialist team, especially nurses

23 Resistant epilepsy Structural brain disease Certain genetic disorders Wrong diagnosis

24 Psychogenic nonepileptic seizures eyes closed rapid breathing prolonged

25 Status epilepticus Follow the protocol Pract Neurol 2014;14:

26 Status epilepticus

27 Management of first seizures Depends upon diagnosis? Long term medication Lifestyle advice Epilepsy nurse specialist

28 Lifestyle advice Safety Driving Common sense Epilepsy Action website

29 Sometimes fatal

30 Take home messages First seizure history and witness is crucial tests are low tech but crucial Epilepsy usually can go home consider clobazam and specialist team Status epilepticus consider non-epileptic attacks follow the protocol

31 If you want to go fast, go alone If you want to go far, go together African proverb