The document discusses definitions of seizures and epilepsy, providing that a seizure is abnormal neuronal activity in the brain and epilepsy is recurrent unprovoked seizures. Epilepsy syndromes describe unique conditions defined by signs and symptoms. Epilepsies are classified based on electroclinical criteria into idiopathic, symptomatic, and cryptogenic types and can be focal, generalized, or undetermined. Causes of focal and generalized seizures are outlined. The management of epilepsy involves a thorough history, physical exam, and differential diagnosis to determine seizure type and etiology.
Sudden temporary change in PHYSICAL movement, SENSATION, BEHAVIOUR because of abnormal discharged of electrical impulses from nerve cells.
CLASSIFICATION
PARTIAL SEIZURE / FOCAL SEIZURE
>> Aimed to determine:
Type of seizure
Frequency
Severity
Aura
LOC
Dyspnea
Fixed and dilated pupil
Incontinence
Factors that precipitate them.
Developmental history taking (events of pregnancy and childbirth)
Questioned about illnesses or head injury
knowing different types of seizure is essential for medical students, clinician and who deal with patients. this slide provide a summary and important points in this field.
During my 1st &2nd year of residency period , i used to teach Anatomy and Orthopaedics for foreign undergraduate medical students. At last year i taught Neurology for one batch. so i posted some of my collections for competely educational purpose coz i believe in knowledge ...inseted of deleting these ppts , they may me useful for others so i shared it ....
Sudden temporary change in PHYSICAL movement, SENSATION, BEHAVIOUR because of abnormal discharged of electrical impulses from nerve cells.
CLASSIFICATION
PARTIAL SEIZURE / FOCAL SEIZURE
>> Aimed to determine:
Type of seizure
Frequency
Severity
Aura
LOC
Dyspnea
Fixed and dilated pupil
Incontinence
Factors that precipitate them.
Developmental history taking (events of pregnancy and childbirth)
Questioned about illnesses or head injury
knowing different types of seizure is essential for medical students, clinician and who deal with patients. this slide provide a summary and important points in this field.
During my 1st &2nd year of residency period , i used to teach Anatomy and Orthopaedics for foreign undergraduate medical students. At last year i taught Neurology for one batch. so i posted some of my collections for competely educational purpose coz i believe in knowledge ...inseted of deleting these ppts , they may me useful for others so i shared it ....
Seizure disorder is one of the important topic in children and adult also. here i explained the seizure disorder in pediatrics, include all most content for nurses level
The slide contains how to take a history of seizure patient when to start and stop AEDs
general introduction of seizure and ILAE classification
anti-epileptic treatment and comorbidities
seizure and heart , lung , liver, kidney diseases
I hope this will help you in exams and also in your clinical practice.
Thank you
This slide was prepared for teaching purpose to medical students. It contain information from different books and medical journals. please inform if any of the information given need to be changed.
Please find the power point on Acute management of seizure. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy.
Seizure disorder is one of the important topic in children and adult also. here i explained the seizure disorder in pediatrics, include all most content for nurses level
The slide contains how to take a history of seizure patient when to start and stop AEDs
general introduction of seizure and ILAE classification
anti-epileptic treatment and comorbidities
seizure and heart , lung , liver, kidney diseases
I hope this will help you in exams and also in your clinical practice.
Thank you
This slide was prepared for teaching purpose to medical students. It contain information from different books and medical journals. please inform if any of the information given need to be changed.
Please find the power point on Acute management of seizure. I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness. If you have two or more seizures or a tendency to have recurrent seizures, you have epilepsy.
-Management of various of forms of epilepsies including treatment of status epilepticus
-Status of newer anti-epileptic drugs in treatment of epilepsies
Definition
Epidemiology
Etiology
Pathophysiology
Classification
Diagnosis
Treatment
Anti Seizure Drugs Prices in Jordan
Two Medical cases
New drug approvals
More than 10 million people suffer from epilepsy in India.Seizures impact the lives of people with epilepsy and their family in many ways including creating barriers to employment and education and facing a sense of discrimination and isolation from their peers who donʼt understand what happens when they see a seizure occur. In India, epilepsy is still thought of as mental illness mainly due to lack of information on the condition among the general public.
This presentation touches every aspect of epilepsy
1. Overview of Epilepsy;
2. Type of Seizures;
3. Diagnosis and Management;
4. Psychological Issues; and
5. Social Perspectives.
Dr Nivedita Bajaj - Basic Facts About Childhood EpilepsyNiveditabajaj
The basics Epilepsy by Dr Nivedita Bajaj , She is a Consultant Paediatrician working within NHS, currently employed by East and North Herts NHS Trust. Dr Bajaj has extensive experience in assessment and management of a wide range of neurodevelopmental conditions and neurodiabilities. She leads clinical autism service in her trust.
Visit - https://drniveditabajaj.blogspot.co.uk/
For more - https://www.nhs.uk/profiles/consultant/6068845
Read More - https://about.me/drniveditabajaj
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. definition
[ Harrison’s Principle 18th ed,pg 6440]
• Seizure
A seizure (from the Latin sacire, "to take
possession of") is a paroxysmal event due to
abnormal excessive or synchronous neuronal
activity in the brain
Consensus Guidelines on the Management
of Epilepsy 2010
2
3. • Epilepsy -describes a condition in which a
person has recurrent unprovoked seizures due
to a chronic, underlying process
• This definition implies that a person with a
single seizure, or recurrent seizures due to
correctable or avoidable circumstances, does
not necessarily have epilepsy
Consensus Guidelines on the Management
of Epilepsy 2010
3
4. • Epilepsy syndrome – complex of signs and
symptoms that define a unique epilepsy
condition
Consensus Guidelines on the Management
of Epilepsy 2010
4
6. Classification of epilepsies and epilepsies syndrome are
based on electroclinical criteria
Described by ‘’International Classification Of Epilepsies
and Epileptic syndrome’’
Mainly divided into 3:
i) Idiopathic : genetically determined and no structural
cause
i) Symptomatic : known cause
ii) Cryptogenic: unknown cause
Consensus Guidelines on the Management
of Epilepsy 2010
6
7. 1) Focal : subdivided to
a) Idiopathic
b) Symptomatic
c) Unknown ( whether symptomatic or idiopathic)
2) Generalized
a) Idiopathic
b) Cryptogenic or symptomatic
c) Symptomatic
3) Undetermined whether focal or generalized
4) Special syndromes
Consensus Guidelines on the Management
of Epilepsy 2010
7
15. examples
• 70 year old who presents with focal seizures
after left middle cerebral artery stroke is said
to have localization-related epilepsy
• A patient who is developmentally challenged
with generalized seizures but normal cerebral
imaging
• 6-year-old, otherwise normal child who
presents with absence seizures
Consensus Guidelines on the Management
of Epilepsy 2010
15
16. Causes
1) Focal Seizures
a) Idiopathic
b) Focal structural lesions
c) Dysembryogenic- sturge weber syndrome
d) Cerebrovascular disease: ICH, cerebral infarction, A-V
malformation, cavernous haemangioma
e) Tumors ( primary and secondary)
f) Trauma: neurosurgery, head injury
g) Infective causes: cerebral abscess, tuberculoma,subdural
empyema
h) Inflammatory causes: sarcoidosis, vasculitis
Consensus Guidelines on the Management
of Epilepsy 2010
16
27. history
HOPI
• When did you experience the first seizure in
your life?
-early neonatal period are usually secondary to
perinatal insults, metabolic disorders, and
congenital malformation.
-70 year old who presents with new onset
seizures is likely to have structural pathology such
as a stroke or brain tumor.
Consensus Guidelines on the Management
of Epilepsy 2010
27
28. • Do you experience some kind of a warning or
unusual feeling at the onset, or immediately
preceding the seizure?
-aura actually represents a simple partial
seizure,and thus indicates that the seizure is focal
in origin
-temporal lobe epilepsy may report a déjà vu
and/or a rising epigastric sensation
-paresthesias may be reported in parietal lobe
epilepsy
-visual distortions or transient blindness
experienced in occipital lobe epilepsy
Consensus Guidelines on the Management
of Epilepsy 2010
28
29. • What happens during the seizure?
-Seizures originating from the frontal eye fields may
cause head and eye deviation to the contralateral side.
-Temporal lobe seizures manisfested with automatism
which most pronounced in the ipsilateral extremity,
along with dystonic posturing
of the contralateral arm.
-Occipital lobe seizures can present with excessive
blinking at the onset, negative visual symptoms or
visual distortions
-Tongue biting and urinary incontinence more often
seen with generalized seizures, complex partial seizures
Consensus Guidelines on the Management
of Epilepsy 2010
29
30. • What happens immediately following the
seizure?(post ictal)
-generalized tonic-clonic seizure goes into a period
of postictal sleep.
-Periods of disorientation and lack of awareness of
the surroundings may follow some complex partial
seizures.
-Hemiparesis or hemiplegia following a seizure
(Todd’s paralysis) is suggestive of a focal onset
-Aphasia with otherwise normal awareness is
suggestive of involvement of the language areas in
the dominant hemisphere.
Consensus Guidelines on the Management
of Epilepsy 2010
30
31. • Is there a diurnal variation?
-tonic-clonic and myoclonic seizures are
more common on awakening or in early morning
-Certain frontal lobe seizures have nocturnal
presentation
• Are there any known triggering factors?
• -sleep deprivation, flickering lights, menses,
alcohol consumption, medication non-
compliance, use of antihistamines, stress,
fever,or exercise
Consensus Guidelines on the Management
of Epilepsy 2010
31
32. • What is the seizure frequency?
• What has been the maximum seizure-free period
since the seizure onset?
• What is the frequency of visits to the emergency
department?
-response to treatment, degree of seizure control
-to determine if any specific antiepileptic drug was
more efficacious than the others.
-specific situation with each hospital visit,such as non-
compliance, changes in the medication,and
concurrent medical illnesses
-frequent hospital visits result from the poor comfort
level of the caregivers, proper education may help
Consensus Guidelines on the Management
of Epilepsy 2010
32
33. • Has the patient sustained injuries related to the
seizures?
-Patients who are injured either do not have auras
or do not have enough time after the aura to take
preventive measures.
-prompt recommendations for wearing a helmet
and modifying the home environment to minimize
injuries.
Consensus Guidelines on the Management
of Epilepsy 2010
33
34. PMH
1.Was the patient the product of a normal full-term
pregnancy, labor, and delivery?
2. Was there any asphyxia or respiratory distress at birth?
3. Were the developmental milestones age-appropriate?
4. Any history of febrile seizures?
5. Any history of central nervous system infections such
as meningitis, encephalitis?In endemic regions, obtain
history of known cysticercosis(JE).
6. Any history of head injuries, especially associated with
depressed skull fracture, intracerebral hemorrhage, loss
of consciousness and prolonged amnesia?
7. History of brain tumor?
8. History of cerebrovascular accident?Consensus Guidelines on the Management
of Epilepsy 2010
34
35. Social hx
• What is your level of education?
• Are you employed? What is your job
description?
-can provide guidance regarding welfare plans and
other kinds of community support.
-office job, as a cashier, or other sedentary tasks
may not be at risk
-construction worker, heavy equipment mechanic,
or someone responsible for supervising others in
high-risk areas, detailed education with some job
modification is critical
Consensus Guidelines on the Management
of Epilepsy 2010
35
36. • Do you drive?
-uncontrolled seizures who have altered awareness
should not be driving
-risk to their personal safety, and endanger other civilians
• Are you sexually active? Do you use contraception?Are
you planning pregnancy in the near future?
-teratogenicity of antiepileptic drugs, the lower efficacy of
oral contraceptives with enzyme-inducing medication
(phenytoin, carbamazepine, and phenobarbital), and the
need for using more than one form of contraception
-daily supplement of folic acid to reduce the risk of neural
tube defects in the newborn
Consensus Guidelines on the Management
of Epilepsy 2010
36
37. • Do you drink alcohol?
-risk factor for a first generalized tonic-clonic seizure
-adversely interact with the metabolism of the
antiepileptic drugs, or may directly result in seizure
exacerbation, especially after continued or binge
drinking
Family hx
-determine specific epilepsy syndromes or other
genetically mediated neurological disorders
Allergic hx and medication
Consensus Guidelines on the Management
of Epilepsy 2010
37
38. Review of systems
*potential side effects of antiepileptic drugs
-Excessive drowsiness:early use of
phenobarbital,gabapentin,and primidone
[carbamazepine, phenytoin,and levetiracetam]
-GIT:more common with carbamazepine
-Weight gain,hair loss,postural tremors:valproic acid
-weight loss and paresthesias: topiramate
-Blurry vision,diplopia, and incoordination:phenytoin,
carbamazepine, and lamotrigine
-Gingival hyperplasia and hirsutism :phenytoin
Consensus Guidelines on the Management
of Epilepsy 2010
38
39. Physical/neurological examination
• Look for stigmata of neurocutaneous syndrome
such as café au lait spots and iris hamartoms with
neurofibramatosis, Ash leaf spots, shahgreen
patches, subungual fibromas, and adenoma
sebaceum [?]
or port-wine stain (capillary hemangioma) [?]
• Look for asymmetries in the size of limbs or one half
of the body (hemiatrophy), which may suggest
perinatal cerebral insult.
Consensus Guidelines on the Management
of Epilepsy 2010
39
40. • Gingival hyperplasia can be seen with phenytoin.
• Dupytrens contractures can be seen with chronic
use of barbiturates.
• Dystonic posturing of one arm on stressed gait,
such as walking on the sides of the feet may
suggest a remote insult to the corticospinal
tracts.
• Multiple bruises or injuries may result from falls
secondary to seizures.
Consensus Guidelines on the Management
of Epilepsy 2010
40
41. investigations
Objectives:
• Clarify the diagnosis of epilepsy and non epileptic
attack
• Determine nature of seizure types and epilepsy
syndrome
• Identify and localization of seizure(partial seizure)
• Identify the aetiology of epilepsy
• Identify concomittant problem,-neurological and
general
• Monitor the progression of condition and
consequences of epilepsy and treatments
Consensus Guidelines on the Management
of Epilepsy 2010
41
42. Blood biochemistry
• Random blood sugar
• Renal profile
• Liver profile
• Serum calcium and magnesium
- Hyponatremia, hypoglycemia,hypomagnesaemia,
uremia and hepatic encephalopathy
• Serum and urine toxicology should be done
when substance abuse or drug overdose is
suspected
Consensus Guidelines on the Management
of Epilepsy 2010
42
43. • A lumbar puncture is indicated if there is any
suspicion of meningitis or encephalitis,
• and it is mandatory in all patients infected
with HIV, even in the absence of symptoms or
signs suggesting infection.
Consensus Guidelines on the Management
of Epilepsy 2010
43
44. Cardiac assessment
• chest radiograph, ECG and echocardiogram are
mandatory in all elderly patient and those
suspected having cardiac disease
• Cardiac arrhythmias and obstruction to cardiac
output may cause generalised seizure
• Heart block relative contraindication to use
carbamazepine
Consensus Guidelines on the Management
of Epilepsy 2010
44
45. Electroencephalography
• except for adult patient with clear metabolic or
structural abnormality on brain imaging
• Types : A)routine interictal scalp EEG
B) Video EEG monitoring
C) Invasive EEG recording/ sphenoidal electrodes
Consensus Guidelines on the Management
of Epilepsy 2010
45
57. Neuroimaging
Structural neuroimaging -MRI or CT brain
-mandatory in following:
• Partial seizure based on history and/or EEG
• Fixed or progressive neurological or psychological
deficit
• Onset of generalised seizure <1yr old & >20 yr old
• Loss of seizure control or status epilepticus,without
clear explanation
• Acutely after significant head trauma
Functional neuroimaging
Consensus Guidelines on the Management
of Epilepsy 2010
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58. Follow up
• repeat EEG and neuroimaging if there is
progression of underlying disease
• Repeat biochemical and haemato profile-side
effect of AED
• If on enzyme inducing AED, repeat FBC,LFT &
serum calcium every 1-2 years
• If on valproate,FBC annually or before surgical
procedure
• Monitor serum AED concentration
Consensus Guidelines on the Management
of Epilepsy 2010
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59. management
Prophylactic treatment
• in head injuries or large haemorrhagic strokes
Single seizures
• high risk of recurrence given option to start
treatment
• Recommendations:
1. Unprovoked GTCS a)a/w previous absence or/&
myoclonic seizure
b)risk of recurrence
Consensus Guidelines on the Management
of Epilepsy 2010
59
60. 2. Simple and complex partial seizure depends on
frequency and severity
3. Seizure d/t alcohol withdrawal,metabolic or drug
related,sleep deprivation NOT be treated with AED
4.Develop seizure within a week of head injury-AED
withdrawal must be considered
5.NOT be treated if uncertain of diagnosis
Consensus Guidelines on the Management
of Epilepsy 2010
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61. Newly diagnosed epilepsy
Factors influencing decision to treat
i) Firm dx of epilepsy- NO TRIAL of treatment to clarify
diagnosis.
ii) Seizure must be sufficiently troublesome-
-if minimal impact/less frequency *benefit of AED< side
effect of AED
iii) Epilepsy Syndrome : Some Benign epilepsy syndrome
have good prognosis without treatment
iv) Compliance : if doubtful, reconsider ( For AEDs to be
effective, it have to be taken regularly &reliably)
Consensus Guidelines on the Management
of Epilepsy 2010
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62. v) Reflex seizures & Acute symptomatic seizures:
Seizures only precipitated under specific
circumstances ( alcohol, photosensitivity), CAN BE
TREATED by avoiding these precipitants.
vi) Patients’ wishes : Final decision left to the
patient. Our role is to explain the relative
advantages and disadvantages of therapy.
Consensus Guidelines on the Management
of Epilepsy 2010
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63. Once Diagnosis is Clear Formulate
Treatment Plan
How?
i)Identify precipitating factors and counsel patients and
their caregivers about their avoidance
ii)COUNSEL patients & caregivers about:
- The reason to start therapy
- Expectations
- Limitations
- Likely duration of therapy
- Need for GOOD compliance
- potential risks of therapy
Consensus Guidelines on the Management
of Epilepsy 2010
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64. iii) Syndromically classify each patients epilepsy
- To choose best medication
- Avoid aggravation/worsening of certain
syndromes/seizure
iv) Start patient on first line single drug therapy
first and adjust dose accordingly.
Monotherapy has better tolerability, compliance
and fewer side effects, simpler regime
Consensus Guidelines on the Management
of Epilepsy 2010
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71. Initiation and maintenance of AEDs
i) Start with Single 1st line drug : guided by types of
seizure/syndrome, hosp. policies, cost, and patients
factors)
ii) Begin with low dose increase gradually over 2-3 wks
( don’t forget to counsel)
iii) Review patient within a month to assess:
-compliance
- Side effects
-seizure control
Consensus Guidelines on the Management
of Epilepsy 2010
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72. iv) Continue review every 6-8 weeks . If seizure
not control AND NO side effects, increase dose
appropriately.
-60%-70% patients achieve good seizure control
with this step
v)If AED fails :
-Review diagnosis and seizure pattern
- Review compliance
- Ensure maximum tolerable dosage have been
used
Consensus Guidelines on the Management
of Epilepsy 2010
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73. vi) IF AED continue to be ineffective
despite maximum tolerable dose..
-introduce an alternative AED slowly WITHOUT tapering the
first
- If good response for the second AED consider
withdrawing the 1st AED gradually
- If Second AED ineffective/produce side effects withdraw
it slowly AND SIMULTANEOUSLY replace it with second add-
on AED from the remaining choices.
- *this process can be repeated with other possible add-on
AEDs
Consensus Guidelines on the Management
of Epilepsy 2010
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74. vii) If seizures are not completely controlled with 2 AEDs
some patient benefit from an additional third AED
viii) If Still persist + period of 2-3 years elapsed(chronic
active epilepsy)
REVIEW diagnosis and aetiology
-reclassify the epilepsy ; possibility of
-NEAD
-POOR COMPLIANCE
-progressive structural lesion ( especially when patient have
partial seizure) surgery maybe considered
-intractable epilepsy : counsel patient and accept their
disability and continue with life
Consensus Guidelines on the Management
of Epilepsy 2010
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75. Decision to withdraw AED
• Can be consider if seizure free for at least 2 years
• exception in certain epilepsy syndrome which
has high relapse rate : eg JME
a) Patient in whom recurrence of seizure less likely
:
- Seizure free for atleast 3-5 or more years
- Those with benign Rolandic and Familial neonatal
Convulsions
Consensus Guidelines on the Management
of Epilepsy 2010
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76. b) Patients with high risk of relapse-
-patient with seizure needing >1 AED
-past h/o status epilepticus
-experience one ore more seizure after treatment has
start
-short duration of seizure freedom
-treatment exceed >10 years
-known aetiology of seizure
-partial onset seizure
-tonic clonic /myoclonic seizure
Consensus Guidelines on the Management
of Epilepsy 2010
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77. Decision of whether to withdraw AEDs should
take into account :
i) Patients need to work and drive a motor
vehicle
ii) Patients fear of seizure and attitude to
prolonged AED therapy
Consensus Guidelines on the Management
of Epilepsy 2010
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78. Social issues and epilepsy :
Driving and epilepsy
• Epileptic seizure can result in road traffic
accident by causing sudden incapacity at the
wheel.
Consensus Guidelines on the Management
of Epilepsy 2010
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79. Decision to drive or not to drive , is a choice best made after
discussions between physician and patients
Some condition that may allow for safe driving include :
i) Well controlled epilepsy and patient is on treatment
ii) Seizure freedom for at least 1 year, on or off treatment
iii) Preceding aura – however aura may not occur with
every seizure , OR driver may have no enough space to
pull over despite and aura signaling an impending
seizure
iv) Purely nocturnal seizure
Consensus Guidelines on the Management
of Epilepsy 2010
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80. Education and epilepsy
• Kementerian Pendidikan Malaysia confirmed ,
person with epilepsy can pursue with higher
education
• Advised to inform the authorities of their
condition , so that modification of
surroundings and courses can be done
Consensus Guidelines on the Management
of Epilepsy 2010
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81. Employement
Major contributing factors :
i) Epilepsy
ii) AEDs side effects ( poor concentration, drowsiness,
reduce cognitive function)
- Encourage to disclose their diagnosis at the workplace
- Absolute rule in employment of patient with epilepsy is not
available
-BUT similar rules in driving can be applied
look for suitable job : according to seizure control, types of
seizure, medication Side effects, intellectual functions
Consensus Guidelines on the Management
of Epilepsy 2010
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82. OTHERs
-stigma and discrimination : associated with
poor psychosocial outcome. Family plays major
role in protecting patients
-Sports : Sport provoked seizure are uncommon.
since sports beneficial to physical health and
also build self confidence, patients choice to
participate or not depending on type of seizures
and with appropriate safety precautions.
Consensus Guidelines on the Management
of Epilepsy 2010
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83. Sexual life in epilepsy
Sexual dysfunction can be a significant but
hidden issues.
An open discussion of this issue with patient
followed by appropriate management can
improve patients lifestyle
Consensus Guidelines on the Management
of Epilepsy 2010
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84. Malaysia Society of epilepsy
• Interaction among people with epilepsy will
enable the sharing experience and emotion.
• Advocating patient initiated support
• www.epilepsy.org.my
Consensus Guidelines on the Management
of Epilepsy 2010
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85. Special medical conditions
-eg : hepatic dysfunction , renal dysfunction,
hypoalbuminemia and acidosis.
Reduces plasma albumin level and binding
affinity increase fractions of free drug
Monitor of free drugs levels in these patient are
necessary to avoid toxicity and improve efficacy
in of AEDs.
Consensus Guidelines on the Management
of Epilepsy 2010
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86. Renally excreted drugs
• Eg : gabapentin, vigabatrin , topiramate,
levetiracetam and phenytoin
• These accumulates in renal failure and
dosages need to be adjusted ( TDM)
Consensus Guidelines on the Management
of Epilepsy 2010
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87. Hepatic dysfunction
Phenobarbitone, phenytoin , and
carbamazepine induce liver enzyme
Use drugs with low protein binding and limited
liver metabolism : eg : gabapentin, topiramate,
vigabatrin.
Don’t forget TDM
Consensus Guidelines on the Management
of Epilepsy 2010
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89. definition
Status epilepticus
• A condition characterized by epileptic seizures
that are sufficiently prolonged
• or repeated at sufficiently brief intervals so as
to produce an unvarying and enduring
epileptic condition (WHO)
Consensus Guidelines on the Management
of Epilepsy 2010
89
90. Refractory status epilepticus
• seizures persisting despite initial treatment with
adequate doses af AEDs(usually benzodiazepine
and one other drug)
• Or SE refractory after 30-60 min of treatment.
Consensus Guidelines on the Management
of Epilepsy 2010
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91. Consensus Guidelines on the Management
of Epilepsy 2010
91
Non convulsive status epilepticus (NCSE)
• no (or only subtle) motor
manisfestations
• Typical presentation:alteration of
awareness ranging from confusion to
coma
• Bizarre behaviours-agitation,
inapproprate laughter,staring,oral
automatism
92. 0-5min
• General measures
6-10min
• Benzodiazepine:
• IV lorazepam, IV Diazepam, Midazolam
10-20min
• IV Phenytoin / Fosphenytoin
• Allergy: IV Valproate, levetiracetam
20-60min
• Anaesthetics : IV Midazolam, IV valpraoate , IV phenobarbitone ,
IV propofol ( most of the time need intubation)
>60min
• IV Pentobarbital
alternate : IV thiopentone
Consensus Guidelines on the Management
of Epilepsy 2010
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95. First line of therapy {6-10 mins}
• Benzodiazepines
-IV lorazepam 2-4 mg [max: 10 mg]
every 5-10 min OR
-IV diazepam 0.2mg/kg(5-10 mg) or rectal
Rate: 5mg/min
repeat after 5 min
[max :3mg /kg/day]
Until seizure stop / significant respiratory depression OR
-Midazolam 10 mg
Intranasal ,buccal or IMConsensus Guidelines on the Management
of Epilepsy 2010
95
96. Second line therapy {10 – 20 mins}
• IV Phenytoin *continuous ECG & BP monitoring
initial loading dose :
-IV 15-20 mg/kg
-diluted in 100 ml NS (via large bore *glucose free saline)
-rate: <50 mg/min OR 25mg/min in elderly/cardiac dx
Additional dose if seizure continue
-5-10 mg/kg [max: 30mg/kg ]
• IV fosphenytoin
-phenytoin pro drug
*in those allergic to phenytoin/hypotension,use IV
valproate or levetiracetam
Consensus Guidelines on the Management
of Epilepsy 2010
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97. If seizure still persists, one of the following
IV Midazolam IV Valproate IV Phenobarbitone IV propofol
load: 0.2 mg/kg
-repeat: 0.2-
0.4mg/kg boluses
every 5 min until
seizure stops
15-40 mg/kg over
10-15 min
-if still seizing,add
20mg/kg over 5-10
min
15-20mg/kg at 500-
100mg/min
Load 1-2mg/kg
Repeat 1-2mg/kg
BOLUSES every 3-5
mins until seizure
stops
MAX : 10mg/kg
STILL Persist
add or switch to
propofol or
pentobarbital
STILL PERSIST switch
to IV midazolam or
propofol
STILL PERSIST
Add or switch to IV
midazolam, propofol,
pentobarbital
STILL PERSIST
Add or switch to
midazolam or
pentobarbital
Consensus Guidelines on the Management
of Epilepsy 2010
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98. >60 min
• IV pentobarbitol
-load:5mg/kg [max: 50mg/min]
-repeat:5mg/kg boluses until seizure stops
-alternative: iv thiopentine
Consensus Guidelines on the Management
of Epilepsy 2010
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99. during management of refractory SE
ventilatory and hemodynamic support needed
If hypotension, infusion should be slowed down
/stopped , and appropriate fluid and vasopressor
given
EEG monitoring essential : to assess response to
treatment
BEFORE WEANING DOWN anaesthetic agents, high
therapeutic range of other AEDs should achieved
and maintained
Anaesthetic agent can be weaned down if seizure
free for >24-48 H.
Consensus Guidelines on the Management
of Epilepsy 2010
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100. 0-5min
• General measures
6-10min
• Benzodiazepine:
• IV lorazepam, IV Diazepam, Midazolam
10-20min
• IV Phenytoin / Fosphenytoin
• Allergy: IV Valproate, levetiracetam
20-60min
• Anaesthetics : IV Midazolam, IV valpraoate , IV phenobarbitone ,
IV propofol ( most of the time need intubation)
>60min
• IV Pentobarbital
alternate : IV thiopentone
Consensus Guidelines on the Management
of Epilepsy 2010
100
101. references
Consensus Guidelines on the Management of
Epilepsy 2010
International League Against Epilepsy
Sarawak Handbook of Medical Emergencies
Wisconsin Medical Journal
Textbook : Harrisons, Davidson
Consensus Guidelines on the Management
of Epilepsy 2010
101
Editor's Notes
Carbamazepine suppressed the conduction in her already defective Purkinje fibres and induced ventricular stand-still with subsequent Adams-Stokes attacks.