Fits, Faints and Funny Turns

Anne Grover

CN1 Neurology

Objectives

To appreciate the wide range of disorders that present with ‘clinical events’

To discuss epileptic ‘lookalikes’To outline history taking

Seizures

Are characterized by a sudden change in movement, behaviour, sensation or consciousness produced by a sudden burst of excessive electrical activity in brain cells causing a chemical (neurotransmitter) imbalance.

Causes of seizures

Brain Tumour

Medications

Drug/ alcoholabuse

Metabolic/ endocrine

Head injury

Stroke

Heart diseaseHigh BP

Fever

Brain infection

Seizures

Epilepsy

Epilepsy – refers to a group of different neurological conditions characterised by recurrent, unprovoked epileptic seizures

A manifestation(s) of epileptic excessive usually self-limiting activity of neurons in the brain

Epilepsy

Affects 1 in 115 peoplePrevalence in Ireland <42 000 people with

epilepsy Approximately 50 million worldwideOne of the most common serious chronic

neurological conditions

1. Joint Epilepsy Council. Epilepsy prevalence, incidence and other statistics. 2011; 2. Brainwave 2009

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FocalFocal dischargesSome loss of awareness

GeneralisedDischarges coming from both hemispheresComplete loss of consciousness

‘Aura’ Motor/sensoryChange in awareness and behaviour

Secondary generalisedUsually tonic clonic convulsion

Absence‘Blank spell’

Myoclonic jerk Twitch/jerk

TonicStiffness

AtonicDrop attack

Tonic clonicConvulsion

SEIZURE CLASSIFICATIONSEIZURE CLASSIFICATION

INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010

IE/BUC/12/0304

Electroclinical syndromes

Defined as an ‘electroclinical’ pattern of clinical features and investigation findings may have different aetiologies.

Common electroclinical syndromes eg- Childhood absence epilepsy - Juvenile absence epilepsy - Juvenile myoclonic epilepsy - Lennox Gastaut

Generalised Tonic Clonic Seizure

Prodromes – non-epileptic clinical alteration prior to onset of an epileptic seizure

Aura – “warning sign” – epileptic seizure experienced prior to GTCS

Initial tonic phase -Epileptic cry, eyes open, roll upwards, jaw clamps shut Limbs stiff & extended, arms may flex, cyanosis

Clonic Phase

Rhythmic jerking of all 4 limbs, jaw & facial muscles

May froth at the mouth, bite tongue, urinary incontinence

Jerking gradually slows before stopping

Itcal phase

Followed by flaccidity of musclesConsciousness slowly regained, may

lapse into deep sleep minutes to hours after

GTCS generally self-limiting, last 1-2 minutes

ACTION

A Assess the situation, ABC’s. Get assistance.

Remove any object that could cause harm

C Cushion patient’s head to protect from injury

T Time, note the time the seizure started

I Identify possible cause

O Over, put patient into recovery position when

possible, note what happened, time seizure ended.

N Never restrain the patient, or put

anything into their mouth.

Provoking factors

Illness or feverSleep deprivationMissing doses AED’sAlcoholStress

Prolonged acute epileptic seizures

Definition of status epilepticus:A seizure lasting >5 minutes, orTwo or more seizures without a return of

consciousness between seizures1

Immediate treatment is recommended for:Prolonged seizures ≥5 minutes, orRepeated convulsive seizures (≥3 in an hour)2

Treatment delay lessens the chance of successful response to a single medication3

Women’s issues

Menstrual cycleFertilityContraceptionPregnancy

Lifestyle implications

• Social issues

• Driving

• Working

• Personal safety

• Good nutrition, special diets

• Memory problems

• Mood changes

Syncope Psychogenic non-epileptic seizures (PNES)Transient ischaemic attackNarcolepsy/cataplexy/sleep apneaSleep-walking, night terrorsPanic attackComplex migraines.Cardiac arrhythmias.

Seizure imitators

Syncope

LOC & postural toneBrief stiffening or spasms & irregular jerks of the

limbsEyes open, roll upwardsUrinary incontinence & traumaGenerally less than 10 secondsConvulsive syncope - 70-90%

Psychogenic non-epileptic seizures

Appear to lose consciousness & fallEyes closedOften lack stereotypical characteristicsJerking may be asymmetric,

asynchronous, wax and wanePelvic thrust, flailing & tremorsVocalise throughoutConsciousness may be retained

GTCS Syncope PNES

J erking of limbs Rhythmical, symmetrical & synchronous

Arrhythmical, asymmetric

Wax and wane, side to side movements& hip thrusting

Duration of event 1-2 minutes 1-30 seconds Often longer

Eyes Open & roll upwards

Open & roll upwards

Often closed

Urinary incontinence & tongue biting

May occur May occur May occur

EEG Abnormal Generalised slowing

Normal awake rhythm

Diagnosis

History

History

History

History

Obtain a detailed account of the event from the patient and a witness

Where, when, what happened?Any warning sign? Any triggers? First event? Other events?Progression- How did it start?After the event?Useful features

Conclusion

Epilepsy is one of the most serious, chronic neurological conditions

Can be difficult to distinguish between imitators

20-30% of patients misdiagnosedA detailed history can assist with

diagnosis

References

Brainwave The Irish Epilepsy Association. Shedding Light on Epilepsy. A nurses information pack.

Epilepsy Ireland. (2009).The prevalence of Epilepsy in Ireland Study. www.epilepsy.ie Murphy, S., Epilepsy-definitions, diagnosis and treatment. Nursing in General Practice. Nizam, S., Spencer, S.S. (2004). An approach to the evaluation of a patient for seizures

and epilepsy. Wisconsin Medical Journal. 103:1. British Paediatric Neurology Association. (2013). Paediatric Epilepsy Training Level One

Handbook. United Kingdom.

Thank you