Epilepsy resident survival guide

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:

• Head trauma
• Brain tumor
• Brain hemorrhage
• Encephalitis
• Hypoglycemia
• Hypoxic encephalopathy
• Stroke

Common Causes

Common causes of epilepsy may include:

• Cerebral palsy
• Electrolyte disturbances
• Epileptic encephalopathy - Lennox-Gastaut type
• Febrile seizures
• Huntington's disease
• Intoxication
• Uremia

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:

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

• Adults with an unprovoked first seizure should be informed that their risk of recurrence is higher within the first 2 years.
• Treat with immediate antiepileptic therapy from the first unprovoked seizure in adults, since it has been seen that it reduces recurrences, as compared with the delay of treatment pending a second seizure. This may not improve quality of life. Benefits and risks of psychological and medical side effects of AED should be evaluated when treating children with an unprovoked first seizure.
• Use Gabapentin in patients aged ≥60 years with new-onset focal epilepsy, as it is as effective and better tolerated than other drugs.
• Lamotrigine should be used to decrease seizure frequency in patients aged ≥60 years.
• Vagus nerve stimulation may be used to reduce seizure frequency over time for periods greater than 6 months and as long as 12 years. In adult patients receiving VNS for epilepsy, improvement in mood may be an additional benefit.
• Adjust dose of antiepileptic drugs in pregnant, since pregnancy may increase the risks of seizure.
• Adjust dosage of antiepileptics such as phenytoin and valproic acid in patients with HIV taking certain antivirals.

Don'ts

• Do not restrain a person with a seizure to try to stop his or her movements.
• Do not put anything object in a person’s mouth during a seizure, since it may injure his teeth or the jaw.
• Do not give water or food to a person with a seizure until he or she is fully alert.
• Do not use cannabinoids in epilepsy. Although, marihuana has been suggested to decrease seizure frequency in epilepsy, there is insufficient studies to support or refute its efficacy.

References

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