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The Anticonvulsants Seizure Classification Partial Seizures : Focal • Simple Partial Seizure –Consciousness Not Impaired –Convulsions limited to one limb –Sensory hallucinations –Common in older children and adults Complex Partial Seizure • Consciousness is impaired briefly • Automatisms present : Automatic behaviors like lip smacking, chewing • Post seizure confusion : 1-2 minutes Partial Become Generalized • Consciousness is impaired • Progressive seizure involvement until a generalized tonic-clonic seizure evolves Generalized Seizures • Absence Seizures (Petit Mal) –Sudden, brief LOC –Amnesia for a brief period –Attacks last <30 seconds –No confused state after seizure –May occur many times per day Myoclonic Seizures –Sudden, lightening fast contractions –Loss of consciousness may occur –Can last seconds to minutes Clonic Seizures –Rhythmic, synchronized contractions throughout the entire body –Loss of consciousness Tonic Seizures –generalized sustained muscle contractions throughout the body –Loss of consciousness Tonic-Clonic Seizures (Grand Mal) –Major convulsions over the entire body –Contractions occur in an alternating tonic and clonic pattern –May loose bowel & bladder control –LOC –May be preceded by an aura or an outcry Atonic Seizures –Sudden loss of postural tone –Consciousness may be lost Anticonvulsants …A Plethora Of Drugs Hydantoins Barbiturates Iminostilbenes Succinimides Benzodiazepines Valproic Acids The Hydantoins Phenytoin (Dilantin) Mephenytoin (Mesantoin) Ethotoin (Peganon) Phenacemide (Phenurone) Phenytoin (Dilantin) - Prototypic Drug • Made in 1908 • Used for seizure control in 1938 • In therapeutic doses, no loss of consciousness Dilantin - Mechanism of Action Stabilizes neural membranes –Interferes w/ sodium ion movement across the cell –May prolong the refractory period of excitable cells by delaying the influx of potassium ions Hydantoins Adverse Side Effects Ataxia Hirsuitism Headache Dysarthria Nystagmus Gingival Hyperplasia The Barbiturates Phenobarbital (Luminal) Mephobarbitol (Mebaral) Primidone (Myosline) Mechanism Of Action Phenobarbital - The Prototype –Anticonvulsant at sub-hypnotic doses –Not addictive in therapeutic doses –Increases threshold for motor cortex stimulation –Reduces neurotransmitter release thereby quieting the brain –May augment the effects of GABA –May inhibit the excitatory effects of glutamate Adverse Side Effects Ataxia Nystagmus Vitamin K deficiency Folic acid deficiency Sedation which diminishes over time The Iminostilbenes Carbamazepine (Tegretol) Mechanism of Action Identical action to the Hydantoins –Stabilizes the flux of sodium across excitable membranes –Inhibits the spread of seizure signaling –First used in 1974 in the U.S. Adverse Side Effects Diplopia Drowsiness Ataxia Hematopoeitic Suppression • Aplastic anemia • Leukopenia • Thrombocytopenia Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) –Water retention –Water intoxication –Increased intraocular pressure Succinimides Ethosuximide (Zarontin) Methusuximide (Celontin) Phensuximide (Milontin) Mechanism of Action Suppress nerve signal transmission in the motor cortex Increase the threshold for stimulation Increase glucose transport to the brain which decreases neuronal excitability Adverse Side Effects Ataxia Dizziness Euphoria Headaches Aplastic Anemia Thrombocytopenia Agranulocytosis Leukopenia Decreased sexual drive Renal and hepatic toxicity Alopecia Hirsuitism Gingival Hyperplasia Stevens-Johnson Disease Target Lesions On The Skin –Central dark red zone with blisters –Encompassed by a pallor area which is circumscribed by a red rim –Necrotic vasculitis may be present (capillary damage) –Bloody discharge from these lesions –May involve the eyes, mouth, lips, tongue, throat, esophagus, gut, bronchopulmonary tree Cause ???? Benzodiazepines Diazepam (Valium) Clonazepam (Klonopin) Clorazapate Dipotassium (Tranxene) Mechanism of Action Enhance the effect of GABA - An inhibitory neurotransmitter Suppresses the spread of seizure signaling produced by epileptogenic foci Adverse Side Effects Vertigo, Ataxia,Syncope Drowsiness, Confusion Tremor, Weakness Valproic Acids Valproate Sodium (Depakene) Divalproex (Depakote) Mechanism of Action Mechanism of action is unknown –Inhibits GABA Transaminase –Inhibits Succinic Semialdehyde Dehydrogenase –Allows GABA to have a longer half-life Anticonvulsants - Medical Uses Used to control seizures The Hydantoins –Trigeminal neuralgia –Cardiac arrhythmias Tegretol –Trigeminal neuralgia –Glossopharyngeal neuralgia Clinical Considerations Is the patient taking their medications regularly ???? Time the rehab session within 30 minutes of the last dose to decrease the chances of seizures Are there any external triggers which could set off the seizure ??? (light, sound, fatigue, odors) Are the patients changing medications or changing the dose ??? Are the patients under unusual stress - divorce, family deaths, etc. Know the side effects of the medications Have a good seizure plan in the clinic Train personnel to appropriately respond to the seizure event