Seizure resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]

Definition

A seizure is a temporary un-synchronized electrical activity in the brain. It can manifest as an alteration in mental state, tonic or clonic movements, convulsions, and various other psychic symptoms (such as déjà vu or jamais vu). Recurrent unprovoked seizure is termed as epilepsy.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. The causes by themselves are usually not life threatening.

Common Causes

• Alcohol withdrawal, illicit drugs, Meds(opioids, antidepressants etc.)

Anatomic abnormalities such as Dandy-Walker Malforamtion etc.

• Alzheimer's and other degenerative disorders

• Brain tumors, trauma

• Cerebrovascular disease

• Intra-cranial infections

• Metabolic(hypoglycemia, uremia etc.) and electrolyte abnormalities(hyponatremia, hypokalemia/hyperkalemia)

Management

AED Therapy

Seizure type	1st choice drug	2nd choice drug	Adjunct therapy
Focal seizure	Carbamazepine/lamotrigine	Leviteracitam/Oxcarbazepine/Sodium valproate	Carbamazepine/Clobazepam/Gabapentin/Lamotrigine/Leviteracitam/Oxcarbazepine/Sodium valproate/Topiramate
Generalized tonic clonic seizure	Sodium valproate/Lamotrigine	Carbamazepine/Oxcarbazepine	Clobazepam/Lamotrigine/Leviteracitam/Sodium valproate/Topiramate
Absence seizure	Ethosuximide/Sodium valproate	Lamotrigine - alone or in combination with 1st choice drugs	Don't use - Carbamazepine/Tiagabine/Gabapentin/Pregabalin/Phenytoin/Oxcarbazepine/Vigabatrin
Myoclonic seizure	Sodium valproate	Leviteracitam/Topiramate	Leviteracitam/Sodium valproate/Topiramate. Avoid drugs as avoided in absence seizure
Idiopathic generalized epilepsy	Sodium valproate	Lamotrigine/Topiramate	Lamotrigine/Leviteracitam/Sodium valproate/Topiramate
Juvenile myoclonic epilepsy	Sodium valproate	Lamotrigine/Leviteracitam/Topiramate	Lamotrigine/Leviteracitam/Topiramate

Anti-epileptic Drug	Avg. daily Dosage
Sodium valproate	750-2000 mg
Lamotrigine	50-400 mg
Phenytoin	300-400 mg
Carbamazepine	400-1200 mg
Ethosuximide	750-1250 mg
Leviteracitam	1000-1500 mg
Phenobarbital	60-150 mg
Gabapentin	900-2400 mg
Oxcarbazepine	600-1200 mg
Topiramate	50-400 mg
Tiagabine	4-48 mg

The Following dosages are based on JAMA 2004 article titled: The new antiepileptic drugs: clinical applications.

Ongoing Seizure

Shown below is an algorithm summarizing the approach to Seizure Management.

Characterize the symptoms: ❑ Aura: altered vision and/or hearing and/or ❑ Tonic phase with muscle spasms and/or ❑ Rapid jerky movement and/or ❑ Uprolling of eyes and/or ❑ Tounge bite and/or ❑ Incontinence

General measures (Emergency): Begin initial care: ❑ Turn patient to side ❑ Secure airway ❑ Assess respiratory and cardiac functions ❑ Administer high concentration O2 ❑ Establish IV access ❑ Institute regular monitoring for pulse, blood pressure, temperature ❑ ECG monitoring ❑ Check glucose level (Urgent) Order labs: ❑ Full blood count ❑ Plasma electrolytes ❑ Blood gases ❑ Glucose ❑ Renal and liver function ❑ Serum calcium and magnesium ❑ Blood clotting br> ❑ Drug levels (if patient is on AED) ❑ Obtain 5 ml of serum and 50 ml of urine sample for toxicology screen Consider vitamin deficiencies: ❑ Administer glucose (50 ml of 50% solution) and/or IV thiamine (250 mg) if suspected alcohol abuse or impaired nutrition ❑ Supplement IV pyridoxine if suspected pyridoxine deficiency Consider the possibility of non-epileptic status Treat acidosis if severe

Administer AED (Emergency): ❑ First line therapy: IV lorazepam(0.1 mg/kg at 2 mg/min) or ❑ Second line therapy: Buccal midazolam (0.3 mg/kg) or rectal diazepam (0.2 mg/kg at 5 mg/min) if IV access could not be established or IV lorazepam is not available

Recurrent or ongoing seizure 10 min after onset? (Urgent) ❑ Repeat the previous regimen only ONCE

Recurrent or ongoing seizure 30 mins after onset? (Urgent) ❑ IV phenytoin(20 mg/kg at 50 mg/min + 5-10 mg/kg): Slow IV infusion, IM is not recommended, monitor ECG during the infusion or ❑ IV fosphenytoin(20 mg/kg PE at 150 mg/min + 5-10 mg/kg): monitor ECG during the infusion or ❑ IV phenobarbital(20 mg/kg at 50–75 mg/min) + 5-10 mg/kg

Ongoing seizure 60 mins after onset? (Urgent) ❑ Intubate and ensure full intensive care support ❑ Anesthetize with midazolam, thiopental or propofol ❑ ICU admission

Resolved Seizure Episode

If patient is not actively seizing at presentation/Once the seizure has resolved, progress to following algorithm.

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Characterize the symptoms: ❑ Aura: altered vision and/or hearing and/or ❑ Tonic phase with muscle spasms and/or ❑ Rapid jerky movement and/or ❑ Uprolling of eyes and/or ❑ Tounge bite and/or ❑ Incontinence

Examine the patient ❑ ❑

Consider alternative diagnosis ❑ ❑

Order labs: ❑ Plasma electrolytes ❑ Random blood sugar(Urgent) ❑ Serum calcium ❑ Toxicology screen ❑ Antiepileptic drugs (AED) levels (if patient already on AED) ❑ BUN/Cr. Order imaging studies: ❑ MRI/CT scan Order EEG studies: ❑ 12 lead EEG

Begin treatment with AED if: ❑ There is a neurological deficit or ❑ EEG shows unequivocal epileptic activity or ❑ Risk of having another seizure unacceptable to pt./family or ❑ Brain imaging shows a structural abnormality

Suspected epileptic seizure

Diagnostic doubt

Refer to specialist in 2 weeks

Refer to specialist

Diagnosis by specialist

Uncertain

Epilepsy

Non-seizure disorder

Further investigations

Classify & treat

Refer to psychologist

Do's

• Consult specialist to make diagnosis, within 2 weeks of presentation.
• Take a detailed history of events to determine if seizure has occured.
• Arrange a follow up.
• Repeated EEG's may be performed if diagnosis is unclear.
• Consider sleep EEG/long term video or ambulatory EEG, if standard EEG hasn't contributed to diagnosis.
• MRI is the imaging of choice in epilepsy esp when:

• Epilepsy first seen in adulthood.
• Focal Onset.
• Seizures continuing despite first line therapy.

Best performed within 4 weeks.

• Consider consulting cardiologist in cases of diagnostic uncertainty.
• Refer for a neuropsychological evaluation if:

• Associated educational or occupational difficulties.
• MRI identified defects in areas important for cognition.
• When pt. complains of cognitive decline.

• Consider monotherapy with one of the 1st choice drugs, if unsuccessful try 2nd choice drugs and only then multi drug therapy.
• Treatment with AED is usually considered after the second seizure.
• Explain teratogenic risks associated with valproate when prescribing to women & girls.
• Do refer to a tertiary care physician if 1st choice and 2nd choice drugs fail.

Dont's

• Do not perform EEG in case of probable syncope because of possibility of false-positive result.
• Do not exclude epilepsy without performing EEG, if other evidence suggest a diagnosis of non-epileptic event.
• Do not make diagnosis with EEG alone.
• Do not perform repeated EEG's if diagnosis is clear.
• Do not forget to provide complete information about the condition and its prognosis.
• Do not start multi drug therapy without consulting a specialist.
• Do not stop the 1st AED abruptly, while switching to a different type.
• Do not monitor blood AED levels routinely. Indications for measuring levels:

• Non adherence.
• Suspected toxicity.
• Adjustment of phenytoin dose.
• Management of drug interactions such as OCP's.
• Specific conditions such as status epilepticus, organ failure etc.

• If pt. is asymptomatic at 2 yrs treatment can be stopped, but do not stop abruptly, taper over 2-3 months.
• Do not stop breast feeding in pregnant women.