approach to epilepsy

8/6/2019 Approach to Epilepsy

1/36

Approach to EpilepsyApproach to Epilepsy

Marina IsmailMarina Ismail

Consultant Physician and NeurologistConsultant Physician and Neurologist

Hospital Raja Perempuan Zainab IIHospital Raja Perempuan Zainab II

KelantanKelantan


2/36

IntroductionIntroduction

Definition:Definition:

Epileptic seizureEpileptic seizure::

paroxysmal stereotyped disturbance ofparoxysmal stereotyped disturbance of

consciousness, motor function, sensation,consciousness, motor function, sensation,emotion, behaviour or perception that on clinicalemotion, behaviour or perception that on clinicalgrounds results from cortical neuronal discharge.grounds results from cortical neuronal discharge.

EpilepsyEpilepsy::

recurrent, usually unprovoked epileptic seizuresrecurrent, usually unprovoked epileptic seizuresthat result from excessive synchronous andthat result from excessive synchronous andabnormal firing patterns of the cerebral corticalabnormal firing patterns of the cerebral corticalneurons.neurons.


3/36

The International Clasification of EpilepticThe International Clasification of Epileptic

SeizuresSeizures

1.1. Partial seizuresPartial seizures

1.1 Simple partial seizure1.1 Simple partial seizure

1.1.1 Motor signs1.1.1 Motor signs

1.1.2 Sensory symptoms1.1.2 Sensory symptoms1.1.3 Autonomic symptoms or signs1.1.3 Autonomic symptoms or signs

1.1.4 Psychic symptoms1.1.4 Psychic symptoms

1.2 Complex partial seizure1.2 Complex partial seizure

1.2.1 Simple partial at onset (with or without automatism)1.2.1 Simple partial at onset (with or without automatism)

1.2.1 With impairment of consciousness (with or without1.2.1 With impairment of consciousness (with or withoutautomatism)automatism)

1.3 Partial seizure evolving into generalized seizure1.3 Partial seizure evolving into generalized seizure


4/36

2. Generalized seizures2. Generalized seizures2.1 Absence seizure2.1 Absence seizure

2.1.1 Typical2.1.1 Typical

2.1.2 Atypical2.1.2 Atypical

2.2 Myoclonic seizure2.2 Myoclonic seizure

2.3 Clonic seizure2.3 Clonic seizure

2.4 Tonic seizure2.4 Tonic seizure

2.5 Tonic2.5 Tonic--clonic seizureclonic seizure

2.6 Atonic seizure2.6 Atonic seizure

3. Unclassified epileptic seizure3. Unclassified epileptic seizure


5/36

International Classification of theInternational Classification of the

epilepsies and epileptic syndromesepilepsies and epileptic syndromes based onbased onelectroclinical criteriaelectroclinical criteria

1.1. LocalizationLocalization--related (focal, local, partial) epilepsies and syndromesrelated (focal, local, partial) epilepsies and syndromes

1.1 Idiopathic (with age1.1 Idiopathic (with age--related onset)related onset)

-- Benign childhood epilepsy with centrotemporal spikesBenign childhood epilepsy with centrotemporal spikes

-- Childhood epilepsy with occipital paroxysmsChildhood epilepsy with occipital paroxysms

-- Primary reading epilepsyPrimary reading epilepsy1.2 Symptomatic1.2 Symptomatic

1.2.1 Characterised by simple partial seizures*1.2.1 Characterised by simple partial seizures*

1.2.2 Characterised by complex partial seizures*1.2.2 Characterised by complex partial seizures*

1.2.3 Characterised by secondarily generalised seizures*1.2.3 Characterised by secondarily generalised seizures*

1.3 Unknown as to whether the syndrome is idiopathic or1.3 Unknown as to whether the syndrome is idiopathic or

symptomaticsymptomatic


6/36

2. Generalised epilepsy and syndromes2. Generalised epilepsy and syndromes

2.1 Idiopathic2.1 Idiopathic

-- Benign neonatal familial convulsionsBenign neonatal familial convulsions

-- Benign neonatal convulsionsBenign neonatal convulsions

-- Benign myoclonic epilepsy in infancyBenign myoclonic epilepsy in infancy

-- Childhood absence epilepsy (pyknolepsy)Childhood absence epilepsy (pyknolepsy)

-- Juvenile absence epilepsyJuvenile absence epilepsy

-- Juvenile myoclonic epilepsyJuvenile myoclonic epilepsy

-- Epilpesy with generalised tonicEpilpesy with generalised tonic--clonic seizures on awakeningclonic seizures on awakening2.2 Cryptogenic or symptomatic2.2 Cryptogenic or symptomatic

-- West SyndromeWest Syndrome

-- LennoxLennox--Gastaut syndromeGastaut syndrome

-- Epilepsy with myoclonicEpilepsy with myoclonic--astatic seizuresastatic seizures

-- Epilepsy with myoclonic absenceEpilepsy with myoclonic absence

2.3 Symptomatic2.3 Symptomatic2.3.1 Non2.3.1 Non--specific aetiologyspecific aetiology

-- Early myoclonic encephalopathyEarly myoclonic encephalopathy

2.3.2 Specific syndromes2.3.2 Specific syndromes

-- Epileptic seizures complicating disease statesEpileptic seizures complicating disease states


7/36

3. Epilepsies and syndromes undetermined, whether focal or3. Epilepsies and syndromes undetermined, whether focal orgeneralisedgeneralised

3.1 With both generalised and focal seizures3.1 With both generalised and focal seizures

-- Neonatal seizuresNeonatal seizures

-- Severe myoclonic epilepsy in infancySevere myoclonic epilepsy in infancy

-- Epilepsy with continuous spike and wave EEG during slowEpilepsy with continuous spike and wave EEG during slow--

wave sleepwave sleep-- Acquired epileptic aphasia (LandauAcquired epileptic aphasia (Landau--Kleffner syndrome)Kleffner syndrome)

3.2 Without unequivocal generalised or focal features3.2 Without unequivocal generalised or focal features

4.4. Special syndromesSpecial syndromes

4.1 Situation4.1 Situation--related seizuresrelated seizures

-- Febrile convulsionsFebrile convulsions

-- Isolated seizures or isolated status epilepticusIsolated seizures or isolated status epilepticus

-- Seizures occurring only when there is an acute metabolic orSeizures occurring only when there is an acute metabolic ortoxic eventtoxic event


8/36

EpilepsiesEpilepsies

Idiopathic: genetically determined and haveIdiopathic: genetically determined and have

no structural cause, no associated clinicalno structural cause, no associated clinical

signs, normal brain imaging and normalsigns, normal brain imaging and normalEEG background.EEG background.

Symptomatic: have known causes.Symptomatic: have known causes.

Cryptogenic: have an underlying cause thatCryptogenic: have an underlying cause thatcannot be documented objectively.cannot be documented objectively.


9/36

How to diagnose epilepsyHow to diagnose epilepsy

HistoryHistory

HistoryHistory

HistoryHistory

Investigations: purposeInvestigations: purpose

-- clarify the diagnosisclarify the diagnosis

-- determine nature of seizure type and epilepsydetermine nature of seizure type and epilepsysyndromesyndrome

-- identify laterality and localizationidentify laterality and localization

-- identify the aetiologyidentify the aetiology-- identify concomitant problems (neurological & general)identify concomitant problems (neurological & general)

-- monitor the progression, consequences and treatmentmonitor the progression, consequences and treatment


10/36

InvestigationsInvestigations

Routine interictal scalp EEG:Routine interictal scalp EEG:

-- all require EEG except adults with a clearall require EEG except adults with a clear

metabolic or structural abnormality on brainmetabolic or structural abnormality on brainimaging.imaging.

-- aim: to clarify, rather than confirm theaim: to clarify, rather than confirm the

diagnosis of epilepsy.diagnosis of epilepsy.-- 50% normal findings.50% normal findings.


11/36

Key EEG features in Idiopathic generalizedKey EEG features in Idiopathic generalizedepilepsy (IGE):epilepsy (IGE):

-- bilaterally synchronous, anteriorlybilaterally synchronous, anteriorly

predominant 3predominant 3--5 Hz spike5 Hz spike--wave activitywave activity-- normal backgroundnormal background

-- photosensitivity in many casesphotosensitivity in many cases

** overnight sleep deprivation may help** overnight sleep deprivation may helpactivate the epileptic discharges in IGE.activate the epileptic discharges in IGE.


12/36

Key EEG features in partial epilepsy:Key EEG features in partial epilepsy:

-- focal or multifocal epileptic dischargesfocal or multifocal epileptic discharges

-- abnormal background in many casesabnormal background in many cases

-- rarely, photosensitivityrarely, photosensitivity

** focal spike may propagate to produce** focal spike may propagate to produce

bilaterally synchronous dischargesbilaterally synchronous discharges

mimicking IGE.mimicking IGE.


13/36

EEG features of generalized epilepticEEG features of generalized epileptic

seizuresseizures

Absence seizuresAbsence seizures -- generalized 3 Hz spikegeneralized 3 Hz spike--wavewaveactivity.activity.

Myoclonic seizuresMyoclonic seizures generalized polyspikes orgeneralized polyspikes or

polyspike and wave activitypolyspike and wave activity Clonic seizuresClonic seizures generalized spikegeneralized spike--wave activitywave activity

Tonic seizuresTonic seizures paroxysmal fast activityparoxysmal fast activity

TonicTonic--clonic seizuresclonic seizures combination of the twocombination of the twoseizure typesseizure types

Atonic Atonic spikes or spikespikes or spike--wave activity or abruptwave activity or abruptflattening eg EEGflattening eg EEG


14/36

EEG features of common epilepsy syndromeEEG features of common epilepsy syndrome

Epilepsy syndromeEpilepsy syndrome EEG backgroundEEG background Epileptic dischargesEpileptic discharges

West SyndromeWest Syndrome AbnormalAbnormal HypsarrythmiaHypsarrythmia--

disorganised high voltagedisorganised high voltage

pattern (spike, slow waves,pattern (spike, slow waves,

periods of attenuation)periods of attenuation)

Benign childhood epilepsyBenign childhood epilepsy

with centrotemporal spikeswith centrotemporal spikes

NormalNormal Unilateral or bilateral,Unilateral or bilateral,

triphasic large amplitudetriphasic large amplitude

spikes maximal in thespikes maximal in the

central or centrotemporalcentral or centrotemporal

region.region.

Benign occipital epilepsyBenign occipital epilepsy NormalNormal Posterior 1.5Posterior 1.5--3 Hz spike3 Hz spikeand slow wave dischargesand slow wave discharges

that attenuate with eyethat attenuate with eye

opening.opening.

LennoxLennox--Gastaut syndromeGastaut syndrome AbnormalAbnormal 11--2.5 Hz generalised,2.5 Hz generalised,

anteriorly predominant spikeanteriorly predominant spike

and slow wave dischargesand slow wave discharges


15/36

VideoVideo--EEG monitoringEEG monitoring

Invasive EEG recording/sphenoidal electrodesInvasive EEG recording/sphenoidal electrodes

Neuroimaging:Neuroimaging:

-- structural neuroimagingstructural neuroimaging

-- functional neuroimagingfunctional neuroimaging

Other investigations:Other investigations:

-- blood biochemistry: RBS, renal, liver profile,blood biochemistry: RBS, renal, liver profile,

serum calcium & magnesiumserum calcium & magnesium

-- cardiac assessment: CXR, ECG,cardiac assessment: CXR, ECG,echocardiogram especially in elderlyechocardiogram especially in elderly

-- investigation for inborn errors of metabolisminvestigation for inborn errors of metabolism


16/36

Other specific investigations:Other specific investigations:

-- serum or CSF VDRLserum or CSF VDRL

-- CSF studiesCSF studies-- HIV serologyHIV serology

-- connective tissue screeningconnective tissue screening

** individualized, ordered judiciously** individualized, ordered judiciously


17/36

Decision to repeat investigations or performDecision to repeat investigations or perform

other investigations must be individualizedother investigations must be individualized

Repeat EEG and neuroimaging: if there is a need toRepeat EEG and neuroimaging: if there is a need toreassess the cause or suspicion that there is progressionreassess the cause or suspicion that there is progressionof the underlying diseaseof the underlying disease

Repeat biochemical and haematological profiles to detectRepeat biochemical and haematological profiles to detectadverse affects of AEDs or to further evaluate adverseadverse affects of AEDs or to further evaluate adverseevents that have already developed.events that have already developed.

In patients taking enzymeIn patients taking enzyme--inducing AEDs, repeat FBC,inducing AEDs, repeat FBC,liver profile & serum calcium every 1liver profile & serum calcium every 1--2 years.2 years.

In patients on valproate, repeat FBC annually or beforeIn patients on valproate, repeat FBC annually or beforesurgical proceduressurgical procedures

Monitoring serum AED concentrationsMonitoring serum AED concentrations


18/36

Differential diagnosisDifferential diagnosis

Neonates and infantsNeonates and infants

-- jittering and benignjittering and benign -- --myoclonusmyoclonus

-- apnoeaapnoea

-- shuddering attacksshuddering attacks

-- gastrogastro--oesophageal refluxoesophageal reflux

Young childrenYoung children

-- breath holding spellsbreath holding spells

-- reflex syncopereflex syncope

-- parasomniasparasomnias

-- benign paroxysmal vertigobenign paroxysmal vertigo-- tics and ritualistic movementstics and ritualistic movements

-- rage attacksrage attacks

AdultsAdults

-- syncopesyncope

-- migrainemigraine

-- transient global amnesiatransient global amnesia

-- TIATIA-- narcolepsynarcolepsy

-- paroxysmal movementparoxysmal movementdisorders and ataxiasdisorders and ataxias

Any ageAny age

-- endocrine, metabolic and toxicendocrine, metabolic and toxic

causescauses-- drug induced dystoniadrug induced dystonia

-- cardiac dysrythmiascardiac dysrythmias

-- deleriumdelerium


19/36

Causes of syncopeCauses of syncope

Neurocardiogenic syncopeNeurocardiogenic syncope

-- vasovagalvasovagal

-- carotid sinus syndromecarotid sinus syndrome

-- micturition syncopemicturition syncope

-- emotional stateemotional state-- cough and otherValsalvacough and otherValsalva--induced syncopeinduced syncope

Psychogenic syncopePsychogenic syncope

-- panic attackpanic attack

-- anxietyanxiety-- hyperventilationhyperventilation

Cardiac syncopeCardiac syncope

-- tachyarrhythmiastachyarrhythmias

-- assystole and heart blockassystole and heart block

-- outflow obstructionoutflow obstruction

-- failing myocardiumfailing myocardium

Vasomotor syncopeVasomotor syncope

-- medicationsmedications

-- postural changespostural changes

-- autonomic neuropathiesautonomic neuropathies

-- peripheral vascular diseaseperipheral vascular disease-- neurodegenerative diseaseneurodegenerative diseasewith orthostatic hypotensionwith orthostatic hypotension

-- blood loss/hypovolemiablood loss/hypovolemia


20/36

Epilepsy management: general principlesEpilepsy management: general principles

Prophylactic treatment.Prophylactic treatment.

--head injuries, large haemorrhagic strokeshead injuries, large haemorrhagic strokes

-- immediate treatment, may reduce risk or earlyimmediate treatment, may reduce risk or early

postpost--traumatic seizurestraumatic seizures-- risk of late postrisk of late post--traumatic epilepsy: no benefittraumatic epilepsy: no benefit

Single seizureSingle seizure

Recurrent seizuresRecurrent seizures

Driving and epilepsyDriving and epilepsy

Education and epilepsyEducation and epilepsy

AED toxicityAED toxicity


21/36

Initiation and continuation of AEDsInitiation and continuation of AEDs

Establish diagnosis and need for long term therapyEstablish diagnosis and need for long term therapy

Start with single first line AEDStart with single first line AED

Begin with low dose, review, increase gradually (6Begin with low dose, review, increase gradually (6--88weeks)weeks)

Counsel and educate patient and familyCounsel and educate patient and family

If AED

fails to control seizures: review diagnosis, reviewIf AED

fails to control seizures: review diagnosis, reviewcompliance, maximum tolerated dosage used.compliance, maximum tolerated dosage used.

Introduce alternative AED slowly if unable to controlIntroduce alternative AED slowly if unable to controlseizures, ? Withdraw first AED/ consider longseizures, ? Withdraw first AED/ consider long--term 2term 2drug therapydrug therapy

Additional third AED, review diagnosis & compliance.Additional third AED, review diagnosis & compliance.

Evaluate for progressive structural lesions, especiallyEvaluate for progressive structural lesions, especiallythose with partial seizures.those with partial seizures.

May consider surgeryMay consider surgery


22/36

List of commonly used drugsList of commonly used drugs

Seizure typeSeizure type First choiceFirst choice Second choiceSecond choice

Partial seizures:Partial seizures:

-- Simple partialSimple partial-- Complex partialComplex partial

-- SecondarilySecondarily

generalisedgeneralised

CarbamazepineCarbamazepineValproateValproate

OxcarbazepineOxcarbazepine

PhenytoinPhenytoinLamotrigineLamotrigine

TopiramateTopiramate

LevetiracetamLevetiracetam

GabapentinGabapentin

PhenobarbitonePhenobarbitone

AcetazolamideAcetazolamide

ClonazepamClonazepam


23/36

Generalised seizuresGeneralised seizures

Seizures typeSeizures type First choiceFirst choice Secon

d choiceSecon

d choiceTonicTonic--clinic, clonicclinic, clonic ValproateValproate

CarbamazepineCarbamazepine

PhenytoinPhenytoin

LamotrigineLamotrigine

TopiramateTopiramate


AcetazolamideAcetazolamideAbsenceAbsence ValproateValproate

EthosuximideEthosuximide




Atypical absences,Atypical absences,

atonic, tonicatonic, tonic

ValproateValproate LamotrigineLamotrigine

TopiramateTopiramateClonazepamClonazepam

PhenytoinPhenytoin



24/36

MyoclonicMyoclonic ValproateValproate ClonazepamClonazepam


PiracetamPiracetam


?Lamotrigine?Lamotrigine

Infantile spasmInfantile spasm ACTHACTH

CorticosteroidCorticosteroid

VigabatrinVigabatrin


ValproateValproate


25/36

Common and important side effects ofCommon and important side effects of

AEDsAEDs

AEDAED Side effects (acute & chronic)Side effects (acute & chronic)CarbamazepineCarbamazepine


GabapentinGabapentin


LevetiracetamLevetiracetam

drowsiness, fatigue, dizziness, ataxia,drowsiness, fatigue, dizziness, ataxia,

diplopia, blurring of vision, rash anddiplopia, blurring of vision, rash and

other skin reactions, leucopenia andother skin reactions, leucopenia and

hyponatremiahyponatremiaSedation, drowsiness, ataxia, blurringSedation, drowsiness, ataxia, blurring

of visionof vision

Drowsiness, dizziness, ataxia,Drowsiness, dizziness, ataxia,

headache, myoclonusheadache, myoclonus

Rash, dizziness, somnolenceRash, dizziness, somnolence

Somnolence, asthenia, dizziness,Somnolence, asthenia, dizziness,

headacheheadache


26/36

AEDAED Side effects (acute & chronic)Side effects (acute & chronic)


PhenytoinPhenytoin

T

opiramateT

opiramate

ValproateValproate

sedation, dizziness, ataxia,sedation, dizziness, ataxia,

hyperactivity in childrenhyperactivity in children

sedation, dizziness, ataxia, lethargy,sedation, dizziness, ataxia, lethargy,

gingival hypertrophy, hirsutismgingival hypertrophy, hirsutism

dizziness, ataxia, paraesthesia,dizziness, ataxia, paraesthesia,

tremor, somnolence, cognitivetremor, somnolence, cognitivedysfunction, emotional lability, worddysfunction, emotional lability, word--

finding difficulties, nephrolithiasis,finding difficulties, nephrolithiasis,

open angle glaucoma, hypohydrosisopen angle glaucoma, hypohydrosis

(children), weight loss.(children), weight loss.Drowsiness, tremor, hair thinning, hairDrowsiness, tremor, hair thinning, hair

loss, menstrual irregularities, weightloss, menstrual irregularities, weight

gain, thrombocytopeniagain, thrombocytopenia


27/36

When to stop treatment??When to stop treatment??

> 60% of patients who remain seizure free,> 60% of patients who remain seizure free,medication an be eventually withdrawnmedication an be eventually withdrawnsuccessfully.successfully.

AED

s should be withdrawn slowly over 6 monthsAED

s should be withdrawn slowly over 6 monthsto 1 year.to 1 year.

Polytherapy, one drug at a time starting with thePolytherapy, one drug at a time starting with theleast useful drug.least useful drug.

Discussion with patients, after 2 years of seizureDiscussion with patients, after 2 years of seizure

free.free. Decision to stop must balance the risks ofDecision to stop must balance the risks of

continuation with the implication of relapse.continuation with the implication of relapse.


28/36

Surgical treatment of EpilepsySurgical treatment of Epilepsy

30% seizure continue despite appropriate drug therapy.30% seizure continue despite appropriate drug therapy.

medically intractable seizures.medically intractable seizures.

Patients whose seizures may be relatively well controlledPatients whose seizures may be relatively well controlled

but have lesions that strongly suggest that surgicalbut have lesions that strongly suggest that surgicalintervention might curative (eg low grade tumours, vascularintervention might curative (eg low grade tumours, vascularmalformations)malformations)

Surgical types: anterior temporal lobectomy, lesionectomy,Surgical types: anterior temporal lobectomy, lesionectomy,functional hemispherectomy, corpus callostomy.functional hemispherectomy, corpus callostomy.

Outcomes: 40Outcomes: 40--80%, depending on the surgical procedures.80%, depending on the surgical procedures. Complications: mortality risk < 1%, morbidity 2Complications: mortality risk < 1%, morbidity 2--5%.5%.


29/36

Status EpilepticusStatus Epilepticus

Definition:Definition:

A seizure or a series of seizures lasting more thanA seizure or a series of seizures lasting more than

30 min, without recovery of full consciousness.30 min, without recovery of full consciousness.

Risk of mortality and morbidity rise with time.Risk of mortality and morbidity rise with time.


30/36

ManagementManagement

Diagnose status epilepticusDiagnose status epilepticus

Assess cardiorespiratory status and vital signs atAssess cardiorespiratory status and vital signs atonset, periodically thereafter.onset, periodically thereafter.

OxygenOxygen

Ensure airway patency and oxygenationEnsure airway patency and oxygenation

Establish IV accessEstablish IV access Blood investigations: glucose, urea &Blood investigations: glucose, urea &

electrolytes, blood count, serum calcium,electrolytes, blood count, serum calcium,magnesium, serum drug levels, ABG.magnesium, serum drug levels, ABG.

If hypoglycemia, administer iv thiamine 100mgIf hypoglycemia, administer iv thiamine 100mgfollowed by d50%.followed by d50%.

Administer in diazepam 0.2 mg/kg at 5 mg/min,Administer in diazepam 0.2 mg/kg at 5 mg/min,repeat after 15 min if seizure persist.repeat after 15 min if seizure persist.


31/36

If seizure persist:If seizure persist:

-- iv phenytoin loading dose 15iv phenytoin loading dose 15--18mg/kg18mg/kg

infusion (in 100 cc NS), rate not more thaninfusion (in 100 cc NS), rate not more than50mg/min. (monitor ECG and BP50mg/min. (monitor ECG and BP

throughout)throughout)

-- maintenance dose: iv 100mg 8 hourly aftermaintenance dose: iv 100mg 8 hourly after

12 hours of loading dose, start oral AED vis12 hours of loading dose, start oral AED vis

RT (if known epileptic on medication)RT (if known epileptic on medication)


32/36

If seizure still persist:If seizure still persist:

-- additional dose of iv phenytoin at 5mg/kgadditional dose of iv phenytoin at 5mg/kg

at rate 50 mg/min (whilst arranging patientat rate 50 mg/min (whilst arranging patientto ICU)to ICU)

OROR

-- iv phenobarbitone 10 mg/kg at 100mg/miniv phenobarbitone 10 mg/kg at 100mg/min


33/36

If seizure persist:If seizure persist:

assisted ventilation:assisted ventilation:

-- iv thiopentone 100iv thiopentone 100--200 mg bolus over 20 seconds, followed by 50 mg200 mg bolus over 20 seconds, followed by 50 mgevery 2every 2--3 min until seizure controlled or EEG shows burst suppression3 min until seizure controlled or EEG shows burst suppression

-- thiopentone maintenance: 3thiopentone maintenance: 3--5 mg/kg/hr5 mg/kg/hr

-- monitor thiopentone blood level 40 microgram/Lmonitor thiopentone blood level 40 microgram/L

-- after 24 hours: infusion based on blood levelsafter 24 hours: infusion based on blood levels

-- after 2after 2--3 days: infusion based on blood levels or decrease dose if3 days: infusion based on blood levels or decrease dose ifSBP < 90 mmHg.SBP < 90 mmHg.

-- slowly discontinue once seizure controlled, after at least 24 hourslowly discontinue once seizure controlled, after at least 24 hourseizure free period.seizure free period.

OROR

-- iv phenobarbitone at 1iv phenobarbitone at 1--4 mg/kg maintenance dose4 mg/kg maintenance dose


34/36

If anaesthetist/ ICU bed not immediately available:If anaesthetist/ ICU bed not immediately available:

-- iv lignocaine 100 mg bolus (1.5iv lignocaine 100 mg bolus (1.5--2 mg.kg) at < 50 mg/min with ECG2 mg.kg) at < 50 mg/min with ECGmonitoringmonitoring

followed byfollowed by

-- in infusion at 50in infusion at 50--11 mg in 250 ml Dextrose 5% at rate of 3mg in 250 ml Dextrose 5% at rate of 3--4 mg/kg/hr4 mg/kg/hr

OROR

-- iv sodium valproate: loading dose 15 mg/kg,iv sodium valproate: loading dose 15 mg/kg,

followed, 30 min later by maintenance dose of 1 mg/kg/min for 6 hours.followed, 30 min later by maintenance dose of 1 mg/kg/min for 6 hours.


35/36

Special Issues: epilepsy in womenSpecial Issues: epilepsy in women

MenstruationMenstruation

FertilityFertility

ContraceptionContraception

PregnancyPregnancy

LabourLabour

Breast feedingBreast feeding Bone healthBone health


36/36

Thank YouThank You

approach to epilepsy

Documents