Acute management of seizure

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1. Acute Management of Seizure Sunil Kumar Daha

2. Seizure A seizure is any abnormal clinical event caused by an abnormal electrical discharge in the brain E pilepsy is the tendency to have recurrent seizures (It is symptom of brain disease rather than a disease itself)

3. Sleep deprivation Alcohol (particularly withdrawal) Recreational drug misuse Physical and mental exhaustion Flickering lights, including TV and computer screens (primary generalized epilepsies only) Intercurrent infections and metabolic disturbances Uncommonly: loud noises, music, reading, hot baths Trigger factors for seizures

4. Emergency Management of Seizure

5. Initially primary survey A: Airway and C-spine B: Breathing C: Circulation D: Disability(AVPU/ GCS) and pupil E: Exposure Secondary survey

6. Stabilization of Airway is Important! Oxygen should be administered by nasal cannula or facemask. An oropharyngeal airway kit and bag valve mask should be ready at bedside, IV line should be established.

7. If the patient is actively seizing… Placed in a lateral decubitus position with the head positioned at a 30-degree angle to minimize aspiration, Seizure precautions: Placing the bed in the lowest position, Any objects that can injure the patient should be removed Making sure that oropharyngeal airway kit and BVM, oxygen, and suction are available at bedside.

8. Immediate care of seizures Little can or need be done for a person during the time a major seizure is occurring except first aid and commonsense maneuvers to limit damage or secondary complications Consists of First Aid Immediate Medical Care

9. First Aid Is to be given by relatives or witnesses Move person away from danger (fire, water, machinery, furniture) After convulsions cease, turn into ‘recovery’ position (semi-prone) Ensure airway is clear, but do NOT insert anything in mouth (tongue-biting occurs at seizure onset and cannot be prevented by observers) If convulsions continue for more than 5 minutes or recur without person regaining consciousness, summon urgent medical attention Do not leave person alone until fully recovered (drowsiness and confusion can persist for up to 1 hour)

10. Immediate medical care Ensure airway is patent Give oxygen to offset cerebral hypoxia Give intravenous anticonvulsant (e.g. diazepam 10 mg) ONLY if convulsions are continuous or repeated (if so, manage as for status epilepticus ) Take blood for anticonvulsant levels (if known epileptic) Investigate cause

11. Anticonvulsant therapy Drug treatment should be considered after more than one episode of seizure has occurred. Of patients whose epilepsy is controllable, only a single drug is necessary in 80%, providing the choice of agent is appropriate and dosage correct. The combination of more than two drugs is seldom necessary. Dose regimens should be kept as simple as possible to promote compliance

12. Guidelines for anticonvulsant therapy Start with one first-line drug Start at a low dose; gradually increase dose until effective control of seizures is achieved or side-effects develop (drug levels may be helpful) Optimize compliance (use minimum number of doses per day) If first drug fails, start second first-line drug whilst gradually withdrawing first If second drug fails, start second-line drug in combination with preferred first-line drug at maximum tolerated dose (beware interactions) If this combination fails (seizures continue or side-effects develop), replace second-line drug with alternative second line drug

13. Contd.. If this combination fails check compliance and reconsider diagnosis (is there an occult structural or metabolic lesion or are seizures truly epileptic?) consider alternative, non-drug treatments (e.g. epilepsy surgery, vagal nerve stimulation) Do not use more than two drugs in combination at any one time

14. Status epilepticus It is defined as a seizure or a series of seizures lasting >5 minutes without patient regaining awareness between the attacks. Most commonly this refers to recurrent tonic clonic seizures (major status) and is a life-threatening medical emergency

15. Management of status epilepticus Initial: Ensure airway is patent, give oxygen to prevent cerebral hypoxia, and secure intravenous access Draw blood for glucose, urea and electrolytes (including Ca and Mg), and liver function, and store a sample for future analysis (e.g. drug misuse) Give diazepam 10 mg i.v . (or rectally) or lorazepam 4 mg i.v .—repeat once only after 15 mins Transfer to intensive care area, monitoring neurological condition, blood pressure, respiration and blood gases, intubating and ventilating patient if appropriate

16. Ongoing: If seizures continue after 30 mins I.v . infusion (with cardiac monitoring) with one of: Phenytoin: 15 mg/kg at 50 mg/min Fosphenytoin : 15 mg/kg at 100 mg/min Phenobarbital: 10 mg/kg at 100 mg/min If seizures still continue after 30–60 mins Start treatment for refractory status with intubation, ventilation, and general anaesthesia using propofol or thiopental Once status controlled Commence longer-term anticonvulsant medication with one of: Sodium valproate 10 mg/kg i.v . over 3–5 mins , then800–2000 mg/day Phenytoin : give loading dose (if not already usedas above) of 15 mg/kg, infuse at < 50 mg/min, then 300 mg/day Carbamazepine 400 mg by nasogastric tube, then400–1200 mg/day Investigate cause

17. References Davidson’s principles and practice of medicine 21 st edition