GENERALISED TONIC CLONIC SEIZURES

Here's a brief look at the case presentation of GTCS.

1. GENERALIZED TONIC-CLONIC SEIZURE Hashim Syed Ali Abbas H 170312882029 PharmD VIth year INTERNSHIP MESCO college of pharmacy

2. GENERALIZED TONIC-CLONIC SEIZURE Tonic-Clonic Seizures Tonic–clonic seizures are a type of generalized seizure that affects the entire brain. The seizures are divided into two phases: Tonic phase The person will quickly lose consciousness, and is characterized by stiffening of the muscles. Clonic phase The person's muscles will start to contract and relax rapidly, causing convulsions this phase is characterized by repetitive, rhythmic jerks that involve both sides of the body at the same time.

3. Clinical features Many patients with generalized tonic-clonic seizures have vision, taste, smell, or sensory changes, hallucinations, or  dizziness  before the seizure. This is called an aura . The seizures usually involve  rigid muscles , followed by violent  muscle contractions , and  loss of alertness (consciousness ).Other symptoms that may include: Biting the cheek or tongue Loss of urine or stool control (incontinence) Stopped breathing  or  difficulty breathing Blue skin color After the seizure, the person may have : Sleepiness Loss of memory (amnesia) regarding events surrounding the seizure episode Headache Drowsiness Confusion Weakness of one side of the body for a few min- to hours following seizure (called Todd paralysis)

4. SUBJECTIVE Patient’s Name: T. Swamy Gender: Male Age: 29years I.P no: 12791 Occupation: Employee

5. Complaints Patient had a GTCS for 30 minutes,followed by total confusion for 10 minutes. H/o Tongue bite Sleep distubance (Nocturnal paroxysmal events eg:sleep apnea ) Past History H/o similar seizures in 2004 and 2012 not on R x Addictions Smoking:Occasionally Alcoholic:2-3 units/week

6. OBJECTIVE Vital Data Lab Investigations →Biochemical Investigations:Normal →Urine Analysis:Normal Day 1 2 3 4 Pulse Rate 80/min 82/min 84/min 82/min B.P 120/80mmHg 130/90mmHg 130/80mmHg 120/80mmHg Resp. Rate 28/min 22/min 24/min 24/min Temperature 98.6 °F 99°F 99°F 98.6°F

7. ASSESSMENT RFT,LFT,FLP,Serum Electrolytes-Normal Hemogram-Normal Colour Doppler Echocardiograph-Normal ECG- Atrial fibrillation is noted CT-Scan- Swelling In Left parietal region of brain(6cm*5cm) Diagnosis K/C/O Generalized Tonic-Clonic Seizures

8. Planning Goals Of Therapy 1 .The goal of treatment in patients with seizures is to achieve a seizure-free status without adverse effects. 2. Prevent relapse or re-occuring of seizures. 3. Avoid or reduce undesirable side-effects that might result from the medication. 4. Begin or return to normal, everyday activities such as work, education, independent living, social relationships.

9. Treatment Options 1.Anti-convulsants :The following five drugs are known to be most effective in the treatment of GTCs: valproate , lamotrigine, topiramate, levetiracetam and zonisamide. → First-line treatment:sodium valproate. 2. Adjunctive treatment : lamotrigine as adjunctive treatment if first-line treatment with sodium valproate is ineffective or not tolerated. 3.surgery →focal resection →hemispherectomy →corpus colostomy surgery 4. Dietary Therapy →Ketogenic Diet(consists of consuming high-fat foods and very few carbohydrates) 5.Other somatic therapies →Vagus nerve stimulation  → Psychological interventions (relaxation, cognitive behaviour therapy)

10. Plan Of Treatment Patient is to be treated with, →Anti-Convulsants :for the prevention from the relaspe or re-occurance of seizures. →PPI’s :to relieve gastric discomfort (adverse effect) → Mild Analgesics/Antipyretics: for the fever. → Muscle relaxants/spasmolytics :centrally acting muscle relaxants to treat muscle spasms.

11. Day-1 →Received tab. Eptoin 100 mg (Phenytoin)on admission. FORMLn Drugs Generic Classification Dose Frequency Route Injection Lavera Levetiracetum Anti-convulsant 1000 mg stat IV Injection Lavera Levetiracetum Anti-convulsant 500 mg BD IV Injection PAN Pantoprazole PPI’s 40mg OD IV Injection Lorazepam lorazepam Benzodiazepines 4mg SOS IV

12. Day-2 →Dolo(antipyretic) was added to decrease fever. →Lorazepam was discontinued,as the pateint sleeps well,without any disturbances. FORMLn Drugs Generic Classification Dose Route Frequency Injection Lavera Levetiracetum Anti-convulsant 500 mg IV BD Injection PAN Pantoprazole PPI’s 40mg IV OD Tablet Tablet Dolo Eptoin Acetaminophen Phenytoin Mild Analgesic Anti Epileptic 650 mg 100 Mg OR P/o SOS BD

13. Day-3 No Addition of drugs,patient’s condition stable was still in observation Day-4 . Day-3 drugs+Addition of drugs, →Powergesic-MR is added to decrease the muscle tone. FORMLn Drugs Generic Classification Dose Route Frequency Tablet Powergesic-MR Chlorzoxazone (500mg) Diclofenac (50mg) Norfloxacin (500mg) Muscle relaxant 1tab OR BD

14. Day-5 No Addition of drugs ,Pateint’s condition was stable and was discharged . Drug Interactions (Significant) Lorazepam+Chlorzoxazone -both increases sedation. Discharge Summary 1. Tab. PAN(Pantoprazole) 40mg OD before breakfast. 2. Tab. Levera(levetiracetum) 500mg OD. 3. Tab. Powergesic-MR(Chlorzoxazone ,Diclofenac ,Norfloxacin) twice daily for 5 days then SOS for pain. 4. Zytee gel(sodium flouride) for L/A.

15. Pharmacist recommendation →Sodium valproate is the first line treatment for tonic-clonic seizures, lamotrigine (if sodium valproate is not suitable). →Alternative first line: treatment carbamazepine, oxcarbazepine. →Patients should be well equipped with the knowledge of the Treatment and its adverse effects. →Dietary Therapy like Ketogenic Diet can be recommended to the patient. →Other somatic therapies like Vagus nerve stimulation can be done if patient is not responding to medications. .

16. Patient’s Counseling →The patient should not be isolated at any point during his full course of treatment. →Educate family about the pateint’s condition and to Inspire them to promote their full support. →Promote medication adherence to prevent relapse or re-occurence of seizures. →Psychological interventions like cognitive behaviour therapy should be recommended,as people with seizures experience psychosocial adjustments after their diagnosis.