Post on 24-Dec-2015
transcript
EPILEPSY &THEEPILEPSY &THEDENTAL DENTAL PATIENTPATIENT
NEUROGENIC DISORDER NEUROGENIC DISORDER
(EPILEPSY)(EPILEPSY) Neurogenic disorder of the brain.Neurogenic disorder of the brain.
Epilepsy:Epilepsy: Is the most common neurogenic Is the most common neurogenic disorder the dentist may face in his clinic.disorder the dentist may face in his clinic.
Potential problems:Potential problems:1.1. Precipitation of the attack.Precipitation of the attack.
2.2. Problems of Problems of drugsdrugs taken taken a) a) PhenytoinPhenytoin-------- Gingival ------ Gingival hyperplasia hyperplasia b) b) ValproateValproate-------- Bleeding tendancy------ Bleeding tendancy
Manifestations of Seizure Manifestations of Seizure Attack:Attack:
Isolated, brief seizureIsolated, brief seizure - Tonic-clonic movement of trunk & - Tonic-clonic movement of trunk &
extremitiesextremities - Loss of consciousness- Loss of consciousness - Vomiting- Vomiting - Airway obstruction- Airway obstruction - Loss of urinary & anal sphincter control- Loss of urinary & anal sphincter control Repeated or sustained seizure (Status Repeated or sustained seizure (Status
Epileptics)Epileptics)
A neurologic disorder characterized by A neurologic disorder characterized by Recurrent Episodes of Seizures.Recurrent Episodes of Seizures.
Grand mal seizure:Grand mal seizure: T Temporary loss of emporary loss of consciousness accompanied by uncontrollable consciousness accompanied by uncontrollable muscular contractions and relaxation.muscular contractions and relaxation. • Phase 1: AuraPhase 1: Aura• Phase 2: Loose consciousness Phase 2: Loose consciousness • Phase 3: Muscle contractionsPhase 3: Muscle contractions• Phase 4: Sleep/recoveryPhase 4: Sleep/recovery
Petit mal seizure:Petit mal seizure: B Brief lapse of rief lapse of consciousness that may last only a few consciousness that may last only a few seconds.seconds.
Epileptic SeizuresEpileptic Seizures
Seizures vs EpilepsySeizures vs Epilepsy
Definition:Definition: the clinical the clinical manifestation of an manifestation of an abnormal and abnormal and excessive excitation of excessive excitation of a population of cortical a population of cortical neuronsneurons
Incidence:Incidence: approximately approximately 80/100,000 per year80/100,000 per year
Lifetime prevalence:Lifetime prevalence: 9% 9% (1/3 benign febrile (1/3 benign febrile convulsions)convulsions)
Definition: a tendency toward recurrent seizures unprovoked by systemic or neurologic insults
Incidence: approximately 45/100,000 per year
Point prevalence: 0.5-1% 14 years or younger
13% 15 to 64 years
63%65 years and older
24%
Cumulative risk of epilepsy through 74 years old: 1.3% - 3.1%
Seizures Epilepsy
Seizure vs EpilepsySeizure vs Epilepsy
Seizures
CardiovascularDrug relatedSyncopeMetabolic (glucose, Na, Ca, Mg)Toxic (drugs, poisons)InfectiousFebrile convulsionsPseudoseizureAlcohol/drug withdrawalSubstance abusePsychiatric disordersSleep disorders (cataplexy)
Nonepileptic Epilepsy(Recurrent Seizures)
Idiopathic(primary)
Symptomatic(secondary)
Questions Raised by a First Questions Raised by a First SeizureSeizure
Seizure or not?Seizure or not?
Focal onset?Focal onset?
Evidence of inter - ictal CNS Evidence of inter - ictal CNS dysfunction?dysfunction?
Metabolic precipitant?Metabolic precipitant?
Seizure type? Syndrome type?Seizure type? Syndrome type?
Start AED?Start AED?
EpilepsyEpilepsy Definition:Definition: a a state of recurrent seizuresstate of recurrent seizures, ,
not due to an identifiable metabolic causenot due to an identifiable metabolic cause May be due to underlying genetic or May be due to underlying genetic or
congenital factors or to cerebral insult congenital factors or to cerebral insult prenatally or later in lifeprenatally or later in life
Background:Background: 1 – 2% of the general population has seizures1 – 2% of the general population has seizures PrimaryPrimary
Idiopathic epilepsy: onset ages 10-20Idiopathic epilepsy: onset ages 10-20 SecondarySecondary
Precipitated by one of the following:Precipitated by one of the following: Intracranial pathologyIntracranial pathology
Trauma, Mass, Abscess, InfarctTrauma, Mass, Abscess, Infarct Extracranial PathologyExtracranial Pathology
Toxic, metabolic, hypertensive, eclampsiaToxic, metabolic, hypertensive, eclampsia
Causes of EpilepsyCauses of Epilepsy
Types of EpilepsyTypes of Epilepsy
1- Partial Seizures1- Partial Seizures -Simple partial seizure
-Complex partial (Psychomotor) seizure
2.Generalized Seizures
- G. Absence seizure (Petit mal)
-Generalize tonic-clonic seizure (Grand mal)
Seizure TypesSeizure Types Generalized Convulsive Seizures (Grand Generalized Convulsive Seizures (Grand
Mal):Mal): Tonic , clonic movements, (+) LOC, apnea, Tonic , clonic movements, (+) LOC, apnea,
incontinence and a post ictal stateincontinence and a post ictal state Non Convulsive Seizures (Petit Mal)Non Convulsive Seizures (Petit Mal)
Absence seizures – “blank staring spells”Absence seizures – “blank staring spells” Myoclonic – brief contractions of selected Myoclonic – brief contractions of selected
muscle groupsmuscle groups Partial SeizuresPartial Seizures
Characterized by presence of hallucinationsCharacterized by presence of hallucinations Simple = somatic complaints + no LOCSimple = somatic complaints + no LOC Complex = somatic complaints + AMS or Complex = somatic complaints + AMS or
LOCLOC
Epilepsy PrecipitantsEpilepsy Precipitants What might cause an otherwise stable patient to have a What might cause an otherwise stable patient to have a
seizure?seizure? Forgetting to take anticonvulsantForgetting to take anticonvulsant Stress –Emotional/PhysicalStress –Emotional/Physical Sleep disturbanceSleep disturbance HypoglycaemiaHypoglycaemia Alcohol withdrawalAlcohol withdrawal
Other medicationsOther medications Anticonvulsants – withdrawal from – esp. benzodiazepinesAnticonvulsants – withdrawal from – esp. benzodiazepines AntidepressantsAntidepressants AntipsychoticsAntipsychotics AntihistaminesAntihistamines AntibioticsAntibiotics CNS stimulantsCNS stimulants
Theophylline, caffeine, cocaine, amphetamineTheophylline, caffeine, cocaine, amphetamine Nonsteroidal anti-inflammatory agentsNonsteroidal anti-inflammatory agents OpiatesOpiates
First Aid - Tonic-Clonic SeizureFirst Aid - Tonic-Clonic Seizure Turn person on side with face turned Turn person on side with face turned
toward ground to keep airway clear, toward ground to keep airway clear, protect from nearby hazardsprotect from nearby hazards
Transfer to hospital needed for:Transfer to hospital needed for: Multiple seizures or status epilepticusMultiple seizures or status epilepticus Person is pregnant, injured, diabeticPerson is pregnant, injured, diabetic New onset seizuresNew onset seizures
DO NOT put any object in mouth or DO NOT put any object in mouth or restrainrestrain
ANTIEPILEPTIC DRUGSANTIEPILEPTIC DRUGS
Phenytoin Carbamazepine Sodium
Valproate Phenobarbital Primidone
Gabapentin Lamotrigine Topiramate Tiagabine Oxcarbazepine Levetiracetam Zonisamide Pregabalin
1st Generation
2nd Generation
Approach for 1Approach for 1stst Seizure, New Seizure, New Seizure, or Substance/ Trauma Seizure, or Substance/ Trauma
Induced SeizureInduced Seizure As always ABC’s First As always ABC’s First IV, O2, Monitor.IV, O2, Monitor.
Send blood for CBC, Chem, Tox screen as appropriateSend blood for CBC, Chem, Tox screen as appropriate Anticonvulsant levelsAnticonvulsant levels Prolactin levels / Lactate levelsProlactin levels / Lactate levels
For seizures that are prolonged—For seizures that are prolonged—i.e.i.e. longer than 5 minutes or longer than 5 minutes or that re-occur without the patient regaining normal that re-occur without the patient regaining normal consciousness – Rx with:consciousness – Rx with: Lorazepam Lorazepam
Is patient still seizing? Post ictal? Pseudoseizure?Is patient still seizing? Post ictal? Pseudoseizure?
Complete History and Physical ExamComplete History and Physical Exam Including detailed Neuro ExamIncluding detailed Neuro Exam Repeat Neuro evaluations a must!Repeat Neuro evaluations a must!
Medical Treatment of First Medical Treatment of First Seizure(s)Seizure(s)
•Whether to treat first seizure is controversial ?
•16-62% will recur within 5 years
•Relapse rate for second seizure is reduced by AEDs,
BUT long term prognosis of whether the patient will have refractory epilepsy is not
•Increased risk of relapse
Abnormal imaging
Abnormal neurological exam
Abnormal EEG
Family history of epilepsy
•Currently, most patients are not treated for the first seizure unless there is an increased risk for relapse
After seizure attackAfter seizure attack
1.1. Place on side and suction Place on side and suction airwayairway
2.2. Monitor vital signsMonitor vital signs3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22
5.5. Prepare to ERPrepare to ER
1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Midazolam 3mg/min IV or Midazolam 3mg/min IV or
IMIM3.3. Phenytoin10~15mg/kg IVPhenytoin10~15mg/kg IV
1.1. Suction airwaySuction airway2.2. Monitor vital signsMonitor vital signs3.3. Administer OAdminister O22
4.4. OBSERVE for at least OBSERVE for at least 1hr and consult 1hr and consult physicianphysician
Patient UnconsciousPatient Unconscious Patient ConsciousPatient ConsciousIf su
sta
ined
If su
sta
ined
Prevention of Peri-operative Prevention of Peri-operative SeizuresSeizures
Patients must take their anticonvulsant Patients must take their anticonvulsant medicationmedication
If general anaesthetic – anaesthetist should be If general anaesthetic – anaesthetist should be aware of seizure tendencyaware of seizure tendency
Check patient’s pre-operative anticonvulsant Check patient’s pre-operative anticonvulsant levelslevels
Consult with patient’s neurologist or family Consult with patient’s neurologist or family physicianphysician
Most stable epileptics, well-controlled on Most stable epileptics, well-controlled on medication, can undergo surgery without medication, can undergo surgery without difficulty or complicationdifficulty or complication
Dental treatment of the E pileptic pati ents AEDs
1. Patient handling
-C hair position -P atient’s head -F alse teeth
2 . Adequate history -Naaaaa aa aaaaaaa -Saaaaaa aaaaaaa -M edi cat i on compl iance
3 . Treatment planni ng
-S t ressf ul si t uaaaaa -a hot i c st i mul aaaaa -Hypogl ycemi a - 4 . Education dentalstaff
aaaaaaaa a& AED
1. Unexplained oral manifestations eg. tttttt tt tttttt ttttttttttt tt ttt tttttt t,, , tttttttt ttttttt;,
A granulocytosis, Thrmbocytopenia
2. Signs of liver damage
4. Cosmetic effects: hirsutism, coarsening of face, widening of jaws, thickening of lips
3. Signs of lymphadenopathyttttttt-ttttttt tttttttt
Valproate & Lamotrigine
- - Stevens Johnson syndrome
- Stevens Johnson syndrome (valproate),
nausea, ataxia
Status EpilepticusStatus Epilepticus
DefinitionDefinition Operationally defined as seizure lasting Operationally defined as seizure lasting
greater than 5 minutes OR two seizures greater than 5 minutes OR two seizures
between which there is incomplete recovery between which there is incomplete recovery
of consciousness.of consciousness. ““Recurrent seizures with failure to Recurrent seizures with failure to
recover from one seizure before next recover from one seizure before next seizure begins”seizure begins”
Status EpilepticusStatus Epilepticus A medical emergencyA medical emergency Adverse consequences can include hypoxia, Adverse consequences can include hypoxia,
hypotension, acidosis and hyperthermiahypotension, acidosis and hyperthermia
Goal: stop seizures as soon as possibleGoal: stop seizures as soon as possible
HypoxiaHypoxia Lactic acidosisLactic acidosis HypercarbiaHypercarbia RhabdomyolysisRhabdomyolysis HyperpyrexiaHyperpyrexia HypoglycaemiaHypoglycaemia
Hypertension Hypertension (early)(early)
ArrhythmiasArrhythmias Neurogenic Neurogenic Hypotension (late)Hypotension (late) AspirationAspiration Injury, burns etcInjury, burns etc
AetiologyAetiology TumourTumour Cerebrovascular disease Cerebrovascular disease Head injuryHead injury Infection Infection Hypoxic encephalopathyHypoxic encephalopathy Drug abuse / overdose / withdrawalDrug abuse / overdose / withdrawal Metabolic Metabolic Primary epilepsy Primary epilepsy PseudoepilepsyPseudoepilepsy
TreatmentTreatment ABC & oxygen & IV accessABC & oxygen & IV access Glucose if indicated or unsure (50mls/D50 Glucose if indicated or unsure (50mls/D50 Diazepam or lorazepam IV (or PR)Diazepam or lorazepam IV (or PR) Phenytoin (to terminate SE or prevent further Phenytoin (to terminate SE or prevent further
fits)fits) Monitor ECG and BPMonitor ECG and BP Investigate & monitor (EEG)Investigate & monitor (EEG) Persistent: Persistent:
> Further phenytoin > Further phenytoin > Phenobarbitone > Phenobarbitone
> Thiopentone > Thiopentone Propofol Propofol
PrognosisPrognosisDepends onDepends on AetiologyAetiology AgeAge Duration of statusDuration of status Systemic complications (anoxia)Systemic complications (anoxia) Treatment givenTreatment given
Mortality: 3 – 35%Mortality: 3 – 35%
Responding to a Patient Experiencing a Responding to a Patient Experiencing a ConvulsionConvulsion
After seizure attackAfter seizure attack
1.1. Place on side Place on side and suction and suction airwayairway
2.2. Monitor vital Monitor vital signssigns
3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22
5.5. Prepare to ERPrepare to ER1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Dormicum 3mg/min IV or Dormicum 3mg/min IV or
IMIM3.3. Dialantin 10~15mg/kg IVDialantin 10~15mg/kg IV
1.1. Suction airwaySuction airway2.2. Monitor vital Monitor vital
signssigns3.3. Administer OAdminister O22
4.4. OBS for at least OBS for at least 1hr and consult 1hr and consult physicianphysician
Patient unconsciousPatient unconscious Patient consciousPatient consciousIf susta
ined
If susta
ined