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.

Algorithm

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

Suspected seizure

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

Initial care(Urgent): ❑ Turn pt. to side ❑ Secure airway/assess resp. & cardiac function ❑ High conc. O2 ❑ Secure IV access

Check labs(Urgent): ❑ Plasma electrolytes ❑ Glucose ❑ Sr. calcium ❑ Tox screen

(Urgent) ❑ Buccal midazolam(0.3 mg/kg) /Rectal diazepam(0.2 mg/kg at 5 mg/min) with a past h/o status epilepticus or ❑ IV lorazepam(0.1 mg/kg at 2 mg/min) if IV access has been established

Ongoing: Lasting > 5 mins or 3 or more seizures in last 1 hr

(Urgent) ❑ Suspected alcohol abuse, IV thiamine ❑ Supplement IV pyridoxine if suspected pyridoxine def.

(Urgent) ❑ Repeat IV lorazepam(0.1 mg/kg at 2 mg/min) after 10 mins

Ongoing

(Urgent) ❑ IV phenytoin(20 mg/kg at 50 mg/min + 5-10 mg/kg) or ❑ IV fosphenytoin(20 mg/kg PE at 150 mg/min + 5-10 mg/kg) or ❑ IV phenobarbital(20 mg/kg at 50–75 mg/min) + 5-10 mg/kg if still seizing 30 mins after onset

Ongoing

(Urgent) ❑ Intubate ❑ Anesthetize with Midazolam, thiopental or propofol ❑ ICU admission

Resolved

Detailed H/o & physical exam

Check labs: ❑ AED levels ❑ MRI/CT scan ❑ 12 lead EEG ❑ BUN/Cr. ❑ Neuropsychiatric evaluation

Treat with AED if: ❑ There is a neurological deficit ❑ EEG shows unequivocal epileptic activity ❑ Risk of having another seizure unacceptable to pt./family ❑ 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.