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Seizure Disorder
 

Seizure Disorder

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    Seizure Disorder Seizure Disorder Presentation Transcript

    • Seizure Disorder
    • Definition • A seizure is a paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of CNS neurons. • Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process.
    • Partial seizures
    • Simple partial seizures
    • Complex partial seizures
    • Partial seizures with secondary generalization
    • Primarily generalized seizures
    • Absence seizures
    • Tonic clonic seizures
    • Tonic Seizures o o When a tonic seizure occurs, the muscles in the body contract and the entire body stiffens And it often causes the person to fall down Atonic seizures o o o Characterised by loss of postural tone lasting 1-2 secs Consciousness is briefly impaired No post ictal confusion Myoclonic seizures o Characterised by sudden and brief contraction of one part of the body or entire body Unclassified Seizures o Seizures that occur in neonates and infants
    • Status epilepticus
    • SEIZURE DISORDER Vineetha Bharathan Menon VI Pharm.D JSSCP
    • Patient details: IP no: 279411 Age: 15 years Weight: 53 kg Sex: Male Unit: Neurology I DOA: 17/1/14 Reason for admission: Recurrence of seizures since 2 days (5 episodes in 2 days lasting 10-20 secs).
    • PMx: K/C/O: seizure disorder since 8 years (since 2010) and on regular medications (T. Phenytoin 50 mg- 0 - 50 mg, T. Clobazam 5 mg 1-0-1, recently started on T. Valproic acid 250 mg 0-0-1). GTCS type of seizures a/w LOC for 2-3 mins Post ictal headache (+) No post ictal confusion Post ictal myalgia (+) h/o cough/ headache (+) No h/o fever in the last week No h/o vomiting
    • Developmental history: Normal hospital vaginal delivery- normal developmental milestones achieved.
    • Provisional diagnosis: Seizure disorder for evaluation
    • Day 1: BP: 130/80 mmHg C/O 6 episodes of GTCS in the morning O/E: skin lesions (+) CNS: conscious oriented, clinically no FND Motor System: Power 5/5, Reflexes (N) CVS: S1S2 (+) R/S: B/L NVBS (+), no added sounds. ADV: Hb, TC, DC, ESR, LFT, Calcium Pulse: 86 bpm
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + simethicone gel 400 mg + 20 mg in 5 ml PO BD + + + + + + Multivitamin 5 ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-0-2 + +
    • Laboratory Data: Hematology: Biochemistry: Hb 14.2 gm/dl (13.5 2 gm/dl) Bilirubin WBC 6,900 cells/cu.mm (400011,000 cells/cu.mm) PLT 2.75 lakhs/cu.mm (1.5-5 lakhs/cu.mm T 0.60 mg/dl (0.1-1.0 mg/dl) D 0.20 mg/dl (0.0-0.2 mg/dl) Total proteins 6.5 gm/dl (6-8 gm/dl) 5 mm/hr (0-10 mm/hr) Electrolytes: Ca 9.6 mg/dl (8.8-10.8 mg/dl) 3.6 gm/dl (3.4-5.0 gm/dl) A/G ratio 1.2 (1.2-2.5) AST 35 U/L (0-40 U/L) ALT ESR Albumin 34 U/L (0-40 U/L) ALP 277 U/L (37-306 U/L)
    • Day 2: BP: 130/80 mmHg Case reviewed, no fresh complaints H/o movement of hands at 4:00 am today O/E no FND, vital stable Rx: as per chart Referred to dermatologist for features suggestive of adenoma sebaceum on face with ash leaf macule on chest. Derma opinion: H/O burning sensation, lesion on nose and malar area, photosensitivity, hypopigmented patches since 7 yrs of age Imp: Xeroderma pigmentosum Start Suntop 30 cream (octinoxate and micronized zinc oxide lotion) and Desowen cream (desonide lotion)
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + simethicone gel 400 mg + 20 mg in 5 ml PO BD + + + + + + Multivitamin 5 ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-02 + +
    • Day 3: BP: 110/80 mmHg Case reviewed, no fresh complaints O/E no FND, vital stable Rx: as per chart, Optho opinion
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + Simethicone gel 400 mg+ 20 mg in 5 ml PO BD + + + + + + Multivitamin 5 ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + domperidone 40 mg+ 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-02 + +
    • Day 4: BP: 110/80 mmHg C/O 7-8 episodes of myoclonic jerks at night CNS: no FND CVS: NAD Rx: as per chart Optho opinion: c/o burning sensation and redness of eyes Imp: NAD
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + simethicone gel 400 mg+ 20 mg in 5 ml PO BD + + + + + + Multivitamin 5ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-0-2 + +
    • Day 5: BP: 126/74 mmHg Case reviewed, no fresh complaints CNS, CVS: NAD Rx: as per chart
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + simethicone gel 400 mg + 20 mg in 5ml PO BD + + + + + + Multivitamin 5 ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-0-2 + +
    • Day 6: BP: 140/80mmHg Case reviewed, no fresh complaints Rx: as per chart
    • Treatment Chart: Drugs Dose Route Frequency D1 D2 D3 D4 D5 D6 Valproic acid 250 mg PO 0-0-1 + Phenytoin Sodium 100 mg PO 1-0-1 + + + + + + Clobazam 10 mg PO 1-0-1 + + + + + + Magaldrate + simethicone gel 400 mg+ 20 mg in 5 ml PO BD + + + + + + Multivitamin 5 ml PO BD + + + + + + Protein powder 1 tsp PO BD + + + + + Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 + + + + + Fosphenytoin 50 mg IV 1-1-1 + + + Lamotrigine 25 mg PO 1-0-1 + + 1-0-2 + +
    • Day 7: BP: 120/80 mmHg Case reviewed, no fresh complaints CNS, CVS: NAD Rx: as per chart Adv: discharge, review after 1 week in OPD
    • Dishcarge medications: Drugs Dose Route Frequency Phenytoin Sodium 100 mg PO 1-0-1 Clobazam 10 mg PO 1-0-1 Magaldrate + simethicone gel 400 mg + 20 mg in 5 ml PO BD Multivitamin 5 ml PO BD Protein powder 1 tsp PO BD Pantoprazole + Domperidone 40 mg + 10 mg PO 1-0-0 Lamotrigine 25 mg PO 1-0-2
    • Pharmaceutical Care Plan: Subjective Evidence Objective Evidence For seizures • Seizures since 2 days • PmHx: K/c/o seizure disorder since 8 years For seizures • Nil For xeroderma pigmentosum • Photosensitivity • Burning sensation and lesion on nose and malar area • Hypopigmentation • Irritation and redness of eyes For xeroderma pigmentosum • Nil
    • Goals of therapy: For seizures • To accurately diagnose the patient's seizure type and epilepsy syndrome and determine the etiology. • To identify and eliminate patient-specific seizure precipitants. • To select optimal anticonvulsant therapy based on seizure type, epilepsy syndrome, patient age, sex, and concomitant medical conditions. • To minimize the use of poly-drug therapy and sedating antiepileptic drugs whenever possible. • To monitor for clinical and laboratory evidence of adverse effects of drug therapy. • To identify and address patient concerns regarding the effect of epilepsy and its management on daily activities, employment, and social interactions.
    • For XP • To protect patient from sunlight and to reduce damaging effect of UV rays on skin
    • Goals achieved: • Seizure was controlled by day 5
    • General treatment options For seizures Seizure type First line agents Second line agents Partial seizures Carbamazepine, phenytoin, lamotrigine, oxcarbazepine, valproic acid Levetiracetam, topiramate, gabapentin, phenobarbital, primidone, felbamate Tonic clonic seizures Valproic acid, lamotrigine, topiramate Zonisamide, penytoin, carbamazepine, oxcarbazepine, phenobarbital, primidone, felbamate Absence seizures Valproic acid, ethosuxcimide Lamotrigine, clonazepam Atypical seizures Atonic siezures Myoclonic seizures Valproic acid, lamotrigine, topiramate Clonazepam, felbamate For XP: sunscreen, vit D supplements, emollients, retinoid preparations, T4N5 lotion
    • Specific treatment options For seizures: GTCS: Valproic acid, lamotrigine, topiramate Multivitamins: vit B complex, vit D & calcium supplementation For XP: avoid exposure to sunlight, sunscreen, emollients, vit D preparations
    • Monitoring parameters: • EEG • Electrolytes: Ca, Mg • Serum glucose • Neurological status DISEASE SPECIFIC • LFTs • CBC • Patients adherence to the medications DRUG SPECIFIC
    • Problems identified: • Drug interactions: valproic acid and phenytoin ( level of phenytoin) phenytoin and lamotrigine ( level of lamotrigine) pantoprazole and clobazam ( effect of clobazam) • Concomitant use of magaldrate and pantoprazole • Phenytoin and clobazam not the apppropriate treatment options for GTCS, moreover phenytoin should not be used in young patients who require long term therapy with phenytoin • Use of protein powder • Concomitant use of phenytoin and fosphenytoin together for 3 days
    • Patient counseling about seizure:
    • Patient counseling about the common signs:
    • Lifestyle modifications • Care takers were informed to give stress free environment • They were advised to monitor him during sleep hours to identify seizure activity • They were asked to visit their doctor regularly • They were informed the benefits of relaxation techniques like deep breathing and meditation • They were told to provide him with healthy diet, including plenty of whole grains, fresh vegetables, and fruits • They were explained the benefit of high fat, no sugar, low protein diet • They were informed to make him wear protective clothes and avoid sun exposure as far as possible
    • Thank you