Epilepsy resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Fahimeh Shojaei, M.D., Moises Romo, M.D.

Synonyms and Keywords: Epilepsy management, Epilepsy workup, Epilepsy approach, approach to Epilepsy, Epilepsy treatment

Overview

Epilepsy is a common chronic neurological disorder that is characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain. Epilepsy can be diagnosed based on history, symptoms and physical examination of a patient with seizure complain. Among the patients who present with clinical signs of seizures, the EEG is the most efficient test for diagnosis. Anti-seizure medications for epilepsy include drugs that affect voltage-dependent Na+ channels, drugs that affect Ca currents, drugs that affect GABA activity, drugs that affect glutamate receptor, and drugs with multiple mechanisms of action.

Causes

Life-threatening Causes

Life-threatening causes of epilepsy include:[1][2][3][4][5][6]

Common Causes

Common causes of epilepsy may include:[7][8][9][10][11][12]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Epilepsy according the the ESC guidelines:


 
 
 
 
 
 
 
 
 
Clinical presentation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Loss of consciousness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Transient?
• Rapid onset?
• Short duration?
• Spontaneous recovery?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Falls
 
Altered consciousnes
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Coma
 
Aborted SCD
 
Others
 
 
 
 
 
 
 
 
 
 
T-LOC
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Traumatic
 
Traumatic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Syncope
 
 
Epileptic seizure
 
 
 
Psychogenic
 
 
Rare causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Reflex syncope
Orthostatic hypotension
Cardiac syncope
 
 
Tonic
Clonic
Tonic-clonic
• Atonic
 
 
 
• Pseudo-epileptic
• Pseudo-syncopal
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of epilepsy according the the American Epilepsy Society guidelines:[13]


 
 
 
 
 
 
 
 
 
Patient with convulsive status epilepticus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Stabilize the patient (airway, breathing, circulation, disability, neurological examination
2. Time seizure from its onset and monitor vital signs
3. Assess oxygenation and give supplemental oxygen or intubate if necessary
4. Initiate ECG monitoring
5. Collect fingerstick blood glucose. If less than 60 mg/dl: Adults: 100 mg thiamine IV then 50 ml of dextrose 50% IV. Children ≥ 2 years: 2 ml/kg dextrose 25% IV Children < 2 years: 4 ml/kg dextrose 12.5% IV
6. Attempt IV access and collect electrolytes, hematology, toxicology screen, (if appropriate) anticonvulsant drug levels)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does seizure continue?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient at baseline, then symptomatic medical care
 
 
 
 
 
A benzodiazepine is the initial therapy of choice (Level A):

1. Choose one of the following 3 equivalent first-line options with dosing and frequency:


• Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose, Level A) OR
• Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose once, Level A) OR
• Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose once, Level A)


2. If none of the 3 options above are available, choose one of the following:


• Intravenous phenobarbital (15 mg/kg/dose, single-dose, Level A) OR
• Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR

• Intranasal midazolam (Level B), buccal midazolam (Level B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does seizure continue?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient at baseline,

then symptomatic

medical care
 
 
 
 
 
There is no evidence based preferred second therapy of choice (Level U):


1. Choose one of the following second line options and give as a single dose


• Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose, Level U) OR
• Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose, Level B) OR
• Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single-dose, Level U)


2. If none of the options above are available, choose one of the following (if not given already)


• Intravenous phenobarbital (15 mg/kg, single dose, Level B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does seizure continue?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient at baseline,

then symptomatic

medical care
 
 
 
 
 
There is no clear evidence to guide therapy in this phase (Level U):


1. Choices include: repeat second line therapy or anesthetic doses of either thiopental,

midazolam, pentobarbital, or propofol (all with continuous EEG monitoring)
 
 
 
 
 


Do's

Don'ts


References

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