Seizure Action Plan/Seizure

Rescue Medication:
Adult Neurology
Timothy Lynch, MD
Assistant Professor of Neurology
Albany Medical Center
Seizure Action Plan
Adult Seizure Action Plan
Adult Seizure Action Plan
• Who gets a formal action plan in an adult epilepsy clinic?
• Children who graduate from peds, and their school requires one every year.
• Adults who live in an institution, and their institution requires one every year.
• Who does not get a formal action plan in an adult epilepsy clinic?
• Everyone else.
Seizure Action Counseling
• What is a seizure.
• What is epilepsy.
• What do Anti-Seizure Medications (ASMs) do.
• What to do if another seizure occurs.
• Physically ensure safety (lower patient to ground, turn them on their side, do
not put anything in their mouth).
• Put on a cup of tea.
• Call me during business hours to discuss.
• If this is a typical seizure, do not have to go to the ER.
When to call 911?
• Physically get hurt requiring ER evaluation.
• Seizure lasts >5 minutes.
• Multiple seizures/cluster seizures.
• The ”seizure” is over, but the patient is not recovering appropriately
from the post-ictal state.
Why No Adult Seizure Action Plan?
• Probably no really good reason.
• Poor physician investment in time…just see the next patient.
• Action plans often can eliminate judgment.
• Legal fears of putting plans in writing.
• But frankly, there can be legal issues if not put in writing.
• They never last…
Adult Seizure Emergency
Treatments
Rescue Medications
• Multiple formulations
• IV
• Best route medically…but you need an IV.
• IM
• Quick and do not need venous access.
• Do not need to be conscious/cooperative.
• Still need a needle.
• PO
• Inexpensive and easy at home.
• Really need to be awake to swallow.
• Variable absorption.
• First pass metabolism.
Rescue Medications
• PR
• Do not have to be awake.
• Can give at home.
• Societally difficult.
• Physically difficult.

• Nasal
• Do not have to be awake.
• Can give at home.
• Societally and physically easy.
Rescue Medications: Are they for everyone?
• Peds?
• Typically more liberal with rescue medications.

• Adult?
• Typically more conservative with rescue medications.

• Who’s right?
Case #1
• 16 year old female with 3 months of myoclonus followed by her first
grand mal seizure the morning after a sleepover at her friend’s house.
• Epilepsy? Yes.
• ASM? Yes.
• Seizure/epilepsy teaching? Yes.
• Rescue med? No.
Case #2
• 25 year old male with Lennox-Gastaut syndrome. Typical seizures are
atonic drop spells for about a second with almost immediate return
to baseline. A typical month includes 10 seizure free days, and the
other days typically have 1-3 seizures. About 1-2 times per month he
will have a day with 5+ seizures, up to 20.
• ASM? Yes.
• Rescue Med? Yes (cluster/acute repetitive seizures).
Case #3
• 16 year old male with an idiopathic generalized epilepsy who
presented initially with grand mal seizures when he was 10.
• GTC seizures were typical: 2-3 minutes followed by a typical post-ictal
state.
• No other seizure types.
• ASM? Yes.
• Rescue med? No.
Case 3: Continued
• Patient is now 18 and is having episodes of myoclonic status that lasts
hours.
• Rescue med? Yes (status epilepticus)
Case #4
• 19 year old male in a psychiatric institution with a 4 year history of
seizures during which his jaw opens forcefully, his head turns to the
right, and he spins to the right. He never loses awareness and is fully
conscious throughout. Duration is typically 2-3 hours, but the shortest
is 20 minutes.
• The patient has never been on an ASM because his prior neurologist
diagnosed pseudoseizures (never admitted for video/EEG
monitoring).
Case #4 Continued
• Epilepsy? Yes, especially after the home video was viewed in the
office (tonic jaw extension with drooling and continued spinning to
the right).
• ASM? Yes
• Rescue Med? Yes (status epilepticus)
• Follow up: Prescribed levetiracetam 500mg bid. Never tried the
rescue med because he never had another seizure.
Adult Rescue Medication Indications
• Prolonged Seizures
• Cluster Seizures/Acute Repetitive Seizures
• But not everyone gets a rescue medication.
• In a study from Bauman and Devinsky (February 2021) 22-34% of outpatient
epileptics experience seizure clusters.
• In a study from Langenbruch et al. (May 2021) 35% of mostly outpatient
epileptics have experienced status epilepticus (seizure > 5 minutes).
• Analogy: Not everyone who has allergies gets an epi pen.
• Rescue medications can limit institutionalized patient activity.
Refinement of Seizure Cluster Prevalence
• Outpatients with epilepsy: 22-34%
• DRE patients with AED withdrawal for presurgical evaluation: 39-61%
• Outpatients with epilepsy who are not seizure free: 52%
• Outpatients with epilepsy who are not seizure free and have >4
seizures per year: 71%
When to PRESCRIBE a Rescue Medication
• History of status epilepticus.
• History of seizure clusters.
• At risk patients:
• All medically refractory? (51%)
• Medically refractory with >4 seizures per year? (71%)
When to GIVE a Rescue Medication
• Seizure lasts >5 minutes
• Or less?
• Multiple/cluster seizures
• But how many???
• The ”seizure” is over, but the patient is not recovering from the post-
ictal state
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