URGENT SEIZURE

MANAGEMENT
Sarah Zaman
Seizures

■ Can be provoked or unprovoked

■ Epilepsy defined as recurrent unprovoked seizures caused by geneticall determined of
acquired brain disorder (trauma, stroke, tumour etc)
■ Up to 10% of general population will have at least one seizure but only 1-3% develop
epilepsy
■ Status epilepticus – seizure lasts more than 5 minutes or recurrent seizures without retun
to baseline mental status
Etiology of Seizures
■ CNS Lesions
■ Metabolic Disturbances – Anoxic or hypoxic insult
– Brain metastases
– Hepatic encephalopathy
– CVA
– Hypocalcemia – Chronic epilepsy
– Hypoglycemia – Acute hydrocephalus
– Hyponatremia – Neurosurgery, head trauma
■ Intoxication
■ Infectious – Bupropion
– Meningitis – Clozapine
– CNS abscess – Cyclosporine
– Imipenem / Metronidazole
■ Withdrawal – Isoniazid
– Alcohol – Lead
– Benzos – Lithium
– TCAs
– Anti-epileptic drugs – Theophylline
Treating Seizures
■ Try to obtain clinical history:
– Any history of trauma?
– Alcohol intoxication or abuse?
– Pregnancy?
■ Febrile seizures – common in pediatric patients, not in adults
– Usually indicates CNS infection in adults (15% of bacterial meningitis have at
least one seizure – may proceed into epilepsy)
■ Any neurologic deficits prior to seizure?
– Stroke is the leading cause of new onset seizures in adults
■ Most common reason for ER visit seizures – noncompliance with anticonvulsants
Status Epilepticus
■ First Line – Benzodiazepines
– Lorazepam – first choice
– Midazolam – IM if no IV access
– Diazepam
■ Second Line
– Phenytoin / Fosphenytoin 15-20 mg/kg IV load
– Valproic Acid 20-40 mg/kg IV load
– (IV Levetiracetam) - 1000-3000 mg bolus over 15 minutes
■ Third Line
– Phenobarbital
– Midazolam infusion
– Propofol infusion
Benzodiazepines

■ Lorazepam – preferred
– Longer central nervous system action (protective from 30-120 minutes)
– Takes longer to stop seizures than diazepam (less fat soluble)
■ Midazolam
– Can be administered IM also with rapid onset of action
– Short duration of action
■ Diazepam
– Fat soluble > rapid brain entry, stops seizures in 1-2 minutes
– IV extravasation can occur, unsuitable for IM use
– Can be administered rectally – esp in pediatrics
■ **all: respiratory depression, hypotension and short duration of action
Phenytoin
■ Too rapid administration can cause bradyarrhythmias and hypotension
– Slower infusion for patients not hemodynamically stable
■ 1 g load not effective in all patients – use weight based 15-20 mg/kg
■ Effect of phenytoin not seen until 40% of the dose has been administered
■ If patient already on phenytoin and actively seizing
– Give half of loading dose
– Cap loading dose at 500 mg
– Use alternative agent such as valproic acid
■ Maintenance dosing – start 12-24 hours post loading dose
■ Levels – can check 6 hours post load or just prior to the next dose
■ Dose increments should not be more than 25-50 mg/day and check levels 5-7 days post dose
change
■ Recheck within 10 days again – further accumulation can occur
Alcohol Related Seizures

■ Acute toxicity and withdrawal both can increase risk of seizures

■ Chronic alcohol abuse linked with trauma, coagulopathy, falls, assaults, other drug
intoxications, hypomagnesemia due to malnutrition– all increase the risk of seizures
also
■ Occur 6-48 hours post cessation of drinking
■ Benzodiazepines – main stay of therapy and valuable in treatment of withdrawal also
(act on the GABA receptor site)
■ Phenytoin ineffective
Drug Related Seizures

■ Benzodiazepines – mainstay of treatment for most drug toxicities causing seizures

■ Phenytoin usually ineffective, can be harmful in theophylline or TCA overdose
■ Phenytoin is usually contraindicated in cases of ingestion toxicities
■ Alkalization – For TCA or salicylate overdose
■ Lithium induced seizures – Hemodialysis
■ Hyponatremia / Hypocalcemia – replace electrolyte
■ Isoniazid – Pyridoxine 5 g IV
Pregnancy
■ Can occur in epileptic patients OR new seizures caused by pregnancy
■ Epileptics – pregnancy increases risk of seizures by 20%
– Protein binding, drug absorption varies during pregnancy
– Noncompliance, sleep deprivation, N/V
– All anticonvulsants cross placenta and are potentially teratogenic
– Usually not drug specific except for neural tube defects seen with valproic acid and carbamazepine
– Generally risk from uncontrolled seizures outweighs potential harm of epilepsy meds
– Risk of status epilepticus related fetal hypoxia and acidosis greater than teratogenicity – treat as a
non-pregnant patient; if more than 24 weeks – fetal monitoring during seizure
■ Eclampsia – seizures after 20 weeks of pregnancy 2' to pregnancy induced triad of HTN, edema and
proteinuria
– Treatment- high dose magnesium infusion (SZ), labetalol infusion (HTN) and expedient delivery of
baby
– If refractory to Mg - benzodiazepines
Question

■ Which is the most common metabolic cause of seizure

activity?
■ Hypercalcemia
■ Hyperglycemia
■ Hypermagnesemia
■ Hypocalcemia
■ Hypoglycemia
Question
■ A 24 year old man is brought to Emerg; the patient's mother reports the patient was
seizing at home for 30 minutes before hospital arrival. Two months ago, the patient
returned from Mexico, where he had been incarcerated for 6 months. The mother
reports during the past 2 months he has been consistently taking his seizure meds and
other pills for a bad lung infection from Mexico. She cannot recall the names of any of
the meds. Several IV doses of lorazepam administered in Emerg – no effect on the
patient's seizure activity. Which of the following meds would be most effective in
stopping his seizues:
– A) Diazepam
– B) Magnesium Sulfate
– C) Phenytoin
– D) Pyridoxine
– E) Valproic Acid
Question

■ Which of the following does NOT increase the risk of

seizures?
– A) acute stroke
– B) chronic stroke related lesions
– C) hyperkalemia
– D) hypomagnesemia
– E) indwelling intracranial shunts