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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
infection
Brain
Tumour
Fever
Heart disease
High BP
Medications
Seizures
Drug/ alcohol
abuse
Stroke
Metabolic/
endocrine
Head injury
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 people
 Prevalence in Ireland <42 000 people with
epilepsy
 Approximately 50 million worldwide
 One of the most common serious chronic
neurological conditions
1. Joint Epilepsy Council. Epilepsy prevalence, incidence and other statistics. 2011; 2. Brainwave 2009
SEIZURE CLASSIFICATION
INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010
Focal
Generalised
Focal discharges
Some loss of awareness
Discharges coming from both hemispheres
Complete loss of consciousness
Tonic clonic
Convulsion
Absence
‘Blank spell’
‘Aura’
Motor/sensory
Change in
awareness and
behaviour
Secondary
generalised
Usually tonic clonic
convulsion
Myoclonic jerk
Twitch/jerk
Atonic
Drop attack
Tonic
Stiffness
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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 muscles
Consciousness 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 fever
Sleep deprivation
Missing doses AED’s
Alcohol
Stress
Prolonged acute epileptic seizures
 Definition of status epilepticus:
 A seizure lasting >5 minutes, or
 Two or more seizures without a return of
consciousness between seizures1
 Immediate treatment is recommended for:
 Prolonged seizures ≥5 minutes, or
 Repeated convulsive seizures (≥3 in an hour)2
 Treatment delay lessens the chance of
successful response to a single medication3
Women’s issues
Menstrual cycle
Fertility
Contraception
Pregnancy
Lifestyle implications
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Social issues
Driving
Working
Personal safety
Good nutrition, special diets
Memory problems
Mood changes
Seizure imitators
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Syncope
Psychogenic non-epileptic seizures (PNES)
Transient ischaemic attack
Narcolepsy/cataplexy/sleep apnea
Sleep-walking, night terrors
Panic attack
Complex migraines.
Cardiac arrhythmias.
Syncope
 LOC & postural tone
 Brief stiffening or spasms & irregular jerks of the
limbs
 Eyes open, roll upwards
 Urinary incontinence & trauma
 Generally less than 10 seconds
 Convulsive syncope - 70-90%
Psychogenic non-epileptic seizures
Appear to lose consciousness & fall
Eyes closed
Often lack stereotypical characteristics
Jerking may be asymmetric,
asynchronous, wax and wane
Pelvic thrust, flailing & tremors
Vocalise throughout
Consciousness may be retained
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 misdiagnosed
A detailed history can assist with diagnosis
References
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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.
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Thank you