A common well-accepted clinical axiom in neurology is "seizures beget seizures." Therefore, seizure prevention, vigorous follow-up, and early therapy are key to success. More important, early treatment is not only more effective, but it also stops progression to status epilepticus. Every time seizures occur, it causes neurological dysfunction despite adequate oxygenation. Thus, it is vital to establish seizure precautions daily.
One factor when considering seizure precautions is knowledge of triggers and precipitating factors. Even though non-compliance with medications is one of the most common causes of breakthrough seizures, all caregivers and healthcare workers should examine these individuals for any underlying metabolic or infectious triggers. In patients with therapeutic drug levels, one should consider fever or any abnormal laboratory parameter as a cause. Substance abuse screening is important in the youth. Imaging studies and electroencephalogram (EEG) are important to establish the risk of seizure recurrence. In almost all cases, the prehospital care of seizure patients is supportive. Most seizures only last a few seconds or minutes, especially the simple febrile seizures in children.
Initial considerations for patients with an ongoing seizure:
The key aim of treatment is to control the seizure before any significant neuronal damage occurs, which usually occurs between 20 to 60 minutes. Anoxia and central nervous system (CNS) infections correlate with a high mortality rate in status epilepticus.
Ensuring Safety Precautions
Both the caregiver and the healthcare provider have an important duty in ensuring the safety of the patient with seizures. It is important to understand that although lifestyle changes and safety precautions are needed, one should avoid becoming too controlling and rigid. People with epilepsy also need to live a good-quality life that offers independence.
During the Seizure
When a seizure occurs, it is important to note:
After the Seizure (Postictal Stage)
After a seizure, most patients experience confusion, fatigue, muscle pain and/or a headache. Thus, one should permit the individual to sleep. For the next few days, reassurance is essential. Being calm and helping reorient the person is also of importance.
Most seizures are painless and end spontaneously. Seizures are not harmful to others but can lead to complications such as stress on the lungs, brain and the heart. Individuals with prior lung problems may develop labored breathing and respiratory distress. Thus, one may need to administer oxygen.
Once the seizure has stopped, record the following:
Conduct a Postictal Exam
Check Blood Work for the Following Triggers
Environmental and Hormonal Triggers
Changes in Activity, Lifestyle, and Restrictions
One of the major problems with recommending seizure precautions is the unpredictability of the seizure recurrence. The onus is on the healthcare provider to discuss the following seizure precautions in patients diagnosed with seizures:
Providers must discuss and document these seizure precautions to prevent any issues including future litigation by the family members. The problem with seizure precautions is that not all seizure patients are alike. Some may only have nocturnal epilepsy, and thus one needs to use judgment in recommending safety maneuvers. For example, patients who practice certain sports like biking and skiing among others should wear a helmet to prevent head traumas.
Drug management of Patients with Active Seizures
The drugs of choice for patient management of active seizures are the benzodiazepines. One may administer intravenous lorazepam or diazepam. If the patient has no intravenous access, then intramuscular midazolam, buccal/nasal midazolam, or rectal diazepam are other options. Intravenous lorazepam is more effective than intravenous diazepam in inducing cessation of the seizure and preventing recurrent seizures.
Doses of 0.1 to 0.2 mg/kg of lorazepam administered over several minutes usually work well, and sometimes higher doses are required to stop the seizure. If the seizure persists, there is no upper limit to the dose of the benzodiazepine (despite a decreased effectiveness over time), but, it is vital to monitor the patient for hypotension and/or respiratory depression.
The current American Epilepsy Society Guidelines published 2016 show three choices for second-line therapy including fosphenytoin, levetiracetam, and valproic acid. There is no evidence that one is superior to the others; however, valproic acid has the highest level of evidence (Level B).
Phenytoin is one of the most widely used anti-seizure medications, classically used as the drug of second choice to end an active seizure. Its use is typically when high doses of benzodiazepines have failed to stop the seizure activity. The initial recommended dose is 20 mg/kg intravenously. However, great caution is required when administering intravenous phenytoin as it can cause arrhythmias, hypotension and even cardiac arrest if the dose is greater than 50 mg per minute. The patient must be monitored during the intravenous infusion. Purple glove syndrome is a rare side effect and can be avoided by limiting infusion rates to less than 25 mg per minute.
Fosphenytoin is a precursor of phenytoin and is safer than phenytoin as it does not contain the diluent propylene glycol. However, fosphenytoin is more expensive than phenytoin. Additionally, fosphenytoin can be administered intramuscularly which is an advantage over phenytoin in patients without intravenous access.
Valproic acid is a weak acid with high serum protein binding. Caution is important with a patient with liver and pancreatic disease. Contraindications include pregnant women with known teratogenic risk of spina bifida, low intelligence quotient, and autism in neonates.
Levetiracetam has the safest side effect profile and least number of drug-drug interactions compared to the three above. It is bioavailable equally in oral and parenteral formulations. It is excreted in urine mostly unchanged; thus, it requires dose adjustment in those with renal disease.
Management Following the End of the Seizures
For those individuals who had a witnessed seizure and now are in the post-ictal phase, supportive care, and seizure precautions are necessary. If the individual had low therapeutic levels of the seizure medications, then it may be appropriate to administer a loading dose in the emergency room before discharge. Reliability of anticonvulsant drug levels varies. The next step following seizure cessation is to look for seizure triggers including toxic/metabolic, stroke, brain mass, iatrogenic, or newly diagnosed epilepsy. Routine blood count, basic metabolic panel, urine drug screen, and urine pregnancy test (when indicated) are considerations for screening. Cranial imaging is indispensable in identifying focal brain abnormalities. Magnetic resonance imaging is superior to conventional computerized tomography scans. Routine EEG has a high diagnostic value in the first 12 to 48 hours following seizure approaching 53.1% versus 23.9%.. Sleep deprivation increases the yield of routine EEG by about 10%. Lumbar puncture should be a diagnostic option in those with suspected meningoencephalitis. However, discharge is only recommended if there are no other issues on clinical presentation.
Individuals who have had 2 or more unprovoked seizures over 24 hours apart can be diagnosed with epilepsy. However, the current standard of care for a single unprovoked seizure is avoiding the triggers. Anticonvulsants are usually not recommended unless the individual has risk factors to endure recurrent seizures. Current evidence does not support starting anti-seizure medications following first-time seizure since it does not change the quality of life; although, it lowers risk for recurrence. However, these patients should see a neurologist within 15 days. Following new onset seizure, patients are counseled about the following risk factors to facilitate the decision making about starting anticonvulsants:
Beside recurrent seizures, consider antiseizure therapy following a single seizure with either abnormal EEG with seizure tendency or abnormal MRI brain. A close follow-up with the primary care provider or the neurologist should be a priority. Before discharge, all patients need to have the drug levels measured to ensure a therapeutic level and compliance. A seizure patient needs indefinite follow up with a primary caregiver or a neurologist.
The decision to discharge patients following a seizure requires good clinical judgment.
To date, there are no data to suggest that any intervention other than prescribed anti-seizure medications can prevent status epilepticus or recurrent seizures. Thus, the most important thing to emphasize to patients is medication compliance. The anti-seizure medication prescribed depends on the patient's underlying diagnosis, severity, pre-existing medications, other comorbidity and potential for drug interactions. A consultation with a neurologist who will oversee and direct the medication prescribed is necessary. Anytime a medication dose or frequency changes, it should be done in consultation with the neurologist.
Discontinuing Anticonvulsant Agents
To discontinue the anticonvulsant agent, the patient has to be seizure free for about 2 to 5 years. Children usually outgrow their epileptic syndromes, and most do not require the use of antiseizure medications in adult life. The relapse rate in children is about 25%, whereas in adults it varies from 40% to 60%. This difference is most likely due to the different epileptic syndromes present in the two populations. Almost 75% of seizure relapses occur within the first 12 months after discontinuation of the medication. About 50% of patients have a seizure within the first 12 weeks. It is therefore critical to educate patients on seizure precautions during the first 3 months after discontinuation of medications; this means absolutely no driving and the Department of Motor Vehicles (DMV) might need to be informed. There are no formal guidelines for discontinuation of antiseizure drugs and roughly done over 8 to 24 weeks. A slower titration recommended for particular drugs such as carbamazepine, oxcarbazepine, phenobarbital, primidone, and benzodiazepines. Before discontinuing anti-seizure medications, it is important to know the risk factors for seizures. A normal EEG and a brain MRI are indicators of a low-risk of recurrence, but if the EEG shows focal abnormalities or MRI brain reveals focal limbic or cortical abnormalities, then the risk of recurrence is higher. Other factors also associated with a high risk of seizure recurrence after discontinuing medication include:
While most patients in the emergency room are manageable without a neurological consultation, consider neurology consult for the following:
If the patient meets the definition of status epilepticus: Status epilepticus is defined as 2 or more subsequent seizures without regaining of consciousness or 30 minutes or more of continuous seizure activity.
Any patient with a known diagnosis of epilepsy who has a breakthrough seizure: Non-adherence with anticonvulsants is a leading cause of the emergence of breakthrough seizures. These patients may need medication change to prevent future seizures.
Prolonged postictal state: Patients are usually admitted to a telemetry floor with close monitoring and further workup.
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