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Contractions with Pronouns Exit TicketContractions with Not ESL 2 Sentences with adjectives and contractions from the verb "to be"Complete the statement with the words in parentheses and the present perfect. Use contractions where possible. [t comes from the GREEK name "Epilepsia" which means "taking hold of or seizing". - It is a disorder characterized by: recurrent seizures. SEIZURES R ectment transient attacks of: R epresent: R esult from: ASSOCIATED WITH: somatic, psychic, or, autonomic clinical featmes. clinical features of abnormally hyperexcitable cortical neurons. paroxvsmal and excessive electrical neuronal discharges. EEG changes & may be disturbance of consciousness. same causes of convulsions 1. Idiopathic epile~ • It is the commonest cause. no cause can be detected ( 65 % ) • It may be associated with positive family history in some cases. • It starts in the l st & 2nd decades in the form of: -- Grand ma! epilepsy. Petit mal epilepsy. Myoclonic epilepsy. Atonic seizures. 2. Secondary epilepsy A. Local causes in the brain: l. Congenital: 2. Traumatic: cerebral palsy. a cause can be detected cerebral contusion or laceration. 3. Inflammatory: 4. Neoplastic: 5. Degenerative: 6. Vascular: encephalitis, brain tumours. mening1t1s, presenile dementia. brain abscess. stroke (especially hemon-hagic), hypertensive encephalopathy. B. General causes with secondary effects on the brain: I. Toxic: 2. Iatrogenic: 3. Metabolic: 4. Endocrinal: 5. Organ failure: 6. Heart disease: 7. Nutritional: - Alcohol, cocaine, lead. - Lidocaine, INH. - j glucose & ! glucose. - Hypoparathyroidism. - Hepatic failme. - Adam's Stoke's attacks. - Pellagra. - Botulism, tetanus. - Ambilhar, Amphetamine, Aminophylline. - j Ca & ! Ca. - Hype1thyroid crisis. - Renal failure. - Fallot's tetralogy. - j Na & ! Na. - Vitamin B6 deficiency. 8. Physical: 9. HYSTERICAL. - High fevers. - Heat stroke. 136 137 CLINICAL PICTURE 1. GENERALISED SEIZURES " Excessive electrical discharges from cortical neurons in BOTH hemispheres simultaneously " I. II. 1. Grand Mal Epile~: 1. Pre-ictal stage "attacks of tonic-clonic convulsions " (aura) It is a warning sign of a coming attack. It may be: • Somatic: • Psychic: • Autonomic: 2. Ictal stage Myoclonus, Hallucinations. Tachycardia, (seizure) Sudden loss of consciousness: Parasthesias. Sweating. for seconds to minutes. -- Tonic phase (few seconds) o The UL & LL: o o o o The HEAD: The JAWS: CYANOSIS: are extended. is retracted to one side & the eye balls rolled up. are firmly clenched, with biting of the TONGUE. due to impaired respiration. There may be incontinence of urine. Clonic phase (few minutes) o The UL & LL: o The HEAD: 3. Post-ictal stage - It may be: • Somatic: • Psychic: • Autonomic: Drug of choice: contract & relax repeatedly & rapidly. jerks forcibly. (sequelae) Todd's paralysis(< 24 hours, due to neuronal exhaustion). Confusion. Vomiting. Carbamazepine (Tegretol) or Phenytoin (Epanutin) Petit Mal Epilepsy: "attacks of loss of consciousness " " Absence " It starts in childhood & improves at puberty & usually disappears at the age of 20. 2. It is NOT PRECEEDED by aura & NOT FOLLOWED by sequelae. 3. It is usually PRECIPITATED by: hyperventilation 4. It is characterized by: or photic stimulation. sudden loss of consciousness of short duration (few seconds). 5. It may be associated with: • High frequency ( 50 attacks / day). • Falling to the ground without warning. • Jerky movements of the head & UL Drug of choice: (myoclonic petit mal). Valproate (Depakine) or Succinimide (Zarontin) 137 138 Ill. M oclonic Seizures: "attacks of involuntary clonic movements " - It is characterized by: sudden, jerky, shock-like INVOLUNTARY muscle contraction. • The jerks are bilateral contractions, mainly of the shoulders and arms. • However, some patients repmtjerking in the lower limbs, trunk, or head. - It may be of 2 types: - Occurs singly • Simple: • As a pait of: I Drug of choice: IV. Atonic seizures: (no loss of consciousness). - Grand mal epilepsy (aura). - Petit mal epilepsy. Valproate (Depakine) or Clonazepam (Rivotril) I - Transient attacks of brief loss of postural tone, often resulting in falls and injuries. 2. PARTIAL SEIZURES "Excessive electrical discharges from cmtical neurons in a ce1tain area in ONE hemisphere" A. Simple seizures: " No disturbance in consciousness " - The CP depends on the site of the hyperexcitable neurones in the cerebral cortex, whether in: "Motor area or Senso,y areas". 1. Motor fits: • Focal fits: • Motor jacksonian fits: 2. General Sensory fits: • Focal fits: • Sensory jacksonian fits: 3. Special Senso1y fits: • Visual hallucinations: • Auditory hallucinations: • Olfactory hallucinations: B. Complex seizures: - SITE: movement of part of a limb or the whole limb. movement of one side of the body (see before). parasthesia of part of a limb or the whole limb. parasthesia of one side of the body (see before). irritation of the visual sensory area. irritation of the auditory sensory area. initation of the uncus. " disturbance in consciousness " The hyperexcitable neurons are in the Temporal lobe "Temporal lobe epilepsy". - DURATION: The seizure lasts few seconds to few minutes. - The seizure starts with A ura, followed by A bsence, Automatism, Amnesia: 1. 2. 3. 4. A ura: A bsence: Automatism: A mnesia: Olfactory hallucinations, Deja-vu phenomenon, Sensation of fear. Absent patient with staring eyes (with no response to conversation). Involuntary Purposeless acts: motor ( eg, lip smacking, chewing) or verbal. No recalling of the seizure. 138 139 3. PARTIAL SEIZURES ~ GENERALISED SEIZURES " Partial seizures may spread to involve the whole brain .- secondarily generalised seizures " . HY-sterical epilepsY • Usually: • The cause: • Incidence: young neurotic Sj2 . psychological & there is no organic lesion. usually occurs in the presence of people. • It is associated with: • EEG: • It is not associated with: normal. • Missed ttt. • Menses. • Alkalosis. anxiety, palpitaion & hyperventilation. tongue biting or incontinence of urine. • Alcohol use & Drug abuse ( e.g. cocaine ). • S timulation by photons & Hyperventilation. • S leep deprivation & Stress & sudden withdrawal of antiepileptic drngs. INVESTIGATIONS 1. EEG: • It is the most specific test for epilepsy because it records the electrical activity of the brain. • It shows specific pattern: 2. LOCAL INVESTIGATIONS: "Epilepsy waves". "CT & MRI of the brain" • To identify or exclude a LOCAL CAUSE of seizures in the brain. 3. GENERAL INVESTIGATIONS: "Laboratory investigations" • To search for a GENERAL CAUSE of seizures, e.g. blood glucose. 139 140 TREATMENT A. General Measures: 1. 2. Moderation of the patient's physical activity. A void the precipitating factors ( Alcohol, hyperventilation, photic stimulation ...... ). 3. A ketogenic diet is encouraged because it will induce acidosis: - Acidosis is beneficial as it raises the threshold of stimulation of the brain cells. B. Specific Treatment: 2. 1. Treatment of the cause in secondary epilepsy. Anti-epileptic drugs: a) Always sta1t with one drug, then add another drug if there is no response. b) Always stop the drugs ONLY if: • The patient stays free of symptoms for at least 2 years. • The patient has a normal EEG. 3. Side effects of Anti-epileptic drugs: I . Skin rash. 2. 3. Bone marrow depression. Ataxia. Drug 1. Barbiturates (Pbenonobarbitone) 2. Hydantoin (Epanutin) 3. Carbamazepine 4. Clonazepam 5. Valproate 6. Succinamide ANTI-EPILEPTIC DRUGS NEW ANTI-EPILEPTIC DRUGS - These drugs are new dtugs that may be used in resistant seizures. 1. Lamotrigine: 200 - 400 mg/ day. 2. Felbamate: 3. Gabapentin: 400- 800 mg/ day. 600 - 1200 mg/ day. \ " General rules for use ": Dose 100-600 mg I day 100-600 mg / day 200-600 mg I day 2-6 mg I day 500-1500 mg I day 500-1000 mg / day Best indicated - Broad spectrum. - Not for petit mal. - Grand mal. - Motor Jacksonian fits. - Grand mal. - Motor Jacksonian fits. - Complex seizures. - Not for petit ma!. - Myoclonic. - Grand mat. - Broad spectrum. - Petit mat. 140 141 STATUS EPILEPTICUS DEFINITION - A medical emergency: 1. Repeated attacks of generalized convulsions, with lack of recove,y of consciousness, 2. Persistent attack of seizure lasting for at least 30 minutes. OR, - If the convulsions are not stopped rapidly, coma deepens & death may occur due to: heart failure or respiratory failure or brain damage or hyperpyrexia. - The most common causes are: sudden withdrawal of anti-epileptic drugs & stroke. TREATMENT A. General Measures: l. Take care of: " ABC " • Place the patient on the ground, to guard against falling from bed. • Mouth gag & 02 inhalation ( endo-tracheal intubation may be needed). • Record the vital signs regularly. 2. Take a sample of: - Venous blood: for the level of: - A.tierial blood: for the level of: 3. a nti-epileptic drugs, a lcohol. pH, p0 2, pC02, HC0 3. Give cerebral dehydrating measures: e.g. Frusemide, cone. Mannitol, Dexamethazone. B. Specific Treatment: - Phenytoin with diazepam (or clonazepam) immediately: 1. Phenytoin: 2. Diazepam: Clonazepam: seizures recur: 15 mg I Kg slow infusion. 5 mg slowly IV, to be repeated after 5 minutes if seizures recur: maximum dose: 20 mg. OR: 2 mg slowly IV, to be repeated after 5 minutes if maximum dose: 6 mg. - If seizures persist after 20 min. of Phenytoin & diazepam: 3. PHENOBARBITONE: - In resistant cases: 200 mg infusion. 4. GENERAL ANAESTHESIA: may be used.Contraction with is, am and are1. SA node sends an impulse causing the atria to contract 2. Blood moves from the right atrium into the right ventricle past the tricuspid valve 3. Blood moves from the left atrium into the left ventricle past the mitral or bicuspid valve 4. Impulse pauses at AV node to allow for maximum blood to be squeezed into the ventricles 5. Impulse travels to the AV bundle (or bundle of His) and down the bundle branches 6. Impulse travels out Purkinje fibers causing the apex to contract 7. The apex contraction increases the blood pressure in the ventricles causing the Mitral and Tricuspid (AV) valves to close. 8. Atria repolarize and begin to fill 9. Purkinje fibers cause the ventricle walls and papillary muscles to depolarize (contract) 10. Papillary muscles hold the AV valves shut (keep them from prolapsing) through the chordae tendineae connection 11. The aortic and pulmonary semilunar valves open when the pressure is higher in the ventricles than in the major arteries 12. Blood moves from right ventricle to pulmonary trunk/arteries past the pulmonary semilunar valve 13. Blood moves from left ventricle to aorta past the aortic semilunar valve 14. Blood pathway is arteries to arterioles, to capillaries (or capillary bed), to venules, veins and vena cava back to the right atrium 15. The ventricles start to repolarize (relax) which decreases the pressure in the ventricles 16. When the pressure is lower in the ventricles than in the major arteries, blood moves back toward heart shutting semilunar valves 17. When the aortic valve closes, the openings to the coronary arteries are exposed 18. Back pressure in the aorta pushes blood out the left and right coronary arteries supplying the heart with oxygenated blood 19. The AV valves open and blood moves from the atria into the ventricles when the ventricular pressure falls below atrial pressure. 20. The process starts again when the SA node fires causing the atria to contract.Many of water’s biological functions stem from its chemical struc- ture. Recall that in the water molecule, H2O, the hydrogen and oxygen atoms share electrons to form covalent bonds. However, these atoms do not share the electrons equally. The oxygen atom has a greater ability to attract electrons to it because it pulls hydrogen’s electrons towards its nucleus. As a result, as shown in Figure 2-8, the region of the molecule where the oxygen atom is located has a partial negative charge, denoted with a , while the regions of the molecule where each of the two hydrogen atoms are located have partial positive charges, each of which are denoted with a . Thus, even though the total charge on a water molecule is neutral, the charge is unevenly distributed across the water molecule. Because of this uneven distribution of charge, water is called a polar compound. Notice also in Figure 2-8 that the three atoms in a water mole- cule are not arranged in a straight line as you might expect. Rather, the two hydrogen atoms bond with the single oxygen atom at an angle. SECTION 3 OBJECTIVES ● Describe the structure of a water molecule. ● Explain how water’s polar nature affects its ability to dissolve substances. ● Outline the relationship between hydrogen bonding and the different properties of water. ● Identify the roles of solutes and solvents in solutions. ● Differentiate between acids and bases. VOCABULARY polar hydrogen bond cohesion adhesion capillarity solution solute solvent concentration saturated solution aqueous solution hydroxide ion hydronium ion acid base pH scale buffer Copyright © by Holt, Rinehart and Winston. All rights reserved. (a) Electron cloud model (b) Space-filling model H H O The oxygen region of the water molecule is weakly negative, and the hydrogen regions are weakly positive. Notice the different ways to represent water, H2O. You are familiar with the electron cloud model (a). The space- filling model (b) shows the three- dimensional structure of a molecule. FIGURE 2-8 40 CHAPTER 2 Hydrogen bond H H H H H H H H H O O O O O O H H H H H – – – – – – – + + + + + + + + + + + + + + The dotted lines in this figure represent hydrogen bonds. A hydrogen bond is a force of attraction between a hydrogen atom in one molecule and a negatively charged region or atom in a second molecule. FIGURE 2-10 The positive region of a water molecule attracts the negative region of an ionic compound, such as the Cl portion of NaCl. Similarly, the negative region of the water molecule attracts the positive region of the compound—the Na portion of NaCl. As a result, NaCl breaks apart, or dissolves, in water. FIGURE 2-9 CI– Na+ H2O + + – – Solubility of Water The polar nature of water allows it to dissolve polar substances, such as sugars, ionic compounds, and some proteins. Water does not dissolve nonpolar substances, such as oil because a weaker attraction exists between polar and nonpolar molecules than between two polar molecules. Figure 2-9 shows how water dissolves the ionic compound sodium chloride, NaCl. In your body, ions, such as sodium and chloride, are essential to bodily func- tions, such as muscle contraction and transmission of impulses in the nervous system. In fact, dissolved, or dissociated ions, are pre- sent in all of the aqueous solutions found in living things and are important in maintaining normal body functions. HYDROGEN BONDING The polar nature of water also causes water molecules to be attracted to one another. As is shown in Figure 2-10, the positively charged region of one water molecule is attracted to the negatively charged region of another water molecule. This attraction is called a hydrogen bond. A hydrogen bond is the force of attraction between a hydrogen molecule with a partial positive charge and another atom or molecule with a partial or full negative charge. Hydrogen bonds in water exert an attractive force strong enough so that water “clings” to itself and some other substances. Hydrogen bonds form, break, and reform with great frequency. However, at any one time, a great number of water molecules are bonded together. The number of hydrogen bonds that exist depends on the state that water is in. If water is in its solid state all its water molecules are hydrogen bonded and do not break. As water liquifies, more hydrogen bonds are broken than are formed, until an equal number of bonds are formed and broken. Hydrogen bonding accounts for the unique properties of water, some of which we will examine further. These properties include cohesion and adhesion, the ability of water to absorb a relatively large amount of energy as heat, the ability of water to cool surfaces through evaporation, the density of ice, and the ability of water to dissolve many substances.