Seizures

Date: ____________		Name: _______________________
Time: ____________		Age: ______ D.O.B. ____________
Allergies: ____________		Medical record number: __________
Weight: _______ lbs ______ kg

1. Admit to [ ] 4G, floor bed [ ] 4G intermediate care [ ] ICU

2. Attending doctor:
3. Admitting diagnosis:
4. Other diagnoses: ______________________________ Pager ______________________________
______________________________
______________________________
______________________________
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5. Condition: [ ] stable [ ] fair [ ] serious [ ] critical
6. Vital signs
[ ] ICU and IMC: Q 2 hours until stable, then routine
[ ] Floor: Q 4 hours until stable, then Q 8 hours

7. Activity: bed rest with seizure precautions
8. Diet [ ] NPO until fully awake and alert [ ] Clear liquids [ ] Regular [ ] no caffeine
9. Nursing: ____________________

10. IV:
[ ] saline lock with routine care
[ ] D5 1/2 NS at 75 cc/hr
[ ] Other: ____________________

11. Monitor:
[ ] pulse oximetry [ ] cardiac telemetry

12. Antiepileptic medications (stat):
[ ] Lorazepam 0.1 mg/kg IVP over 5 minutes
[ ] Cerebyx (fosphenytoin) 27 mg/kg IV at a rate not faster than 200 mg/min.
[ ] Phenytoin 15 mg/kg PO Q 4 hours for 3 doses

13. Antiepileptic medications (routine) :
[ ] Cerebyx (fosphenytoin) 7.5 mg/kg IV Q 8 hours
[ ] Phenytoin 100 mg PO TID
[ ] Dilantin 300 mg PO QD
[ ] Other antiepileptic medications:

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14. Antiepileptic medications (PRN):
[ ] Lorazepam 2 - 4 mg slow IVP over 10 minutes, PRN seizure over 3 minutes duration

15. Other medications:
[ ] Acetaminophen 650 mg PO Q 4 - 6 hours PRN pain or fever
[ ] Zolpidem (Ambien) 10 mg at HS PRN sleep

16. Labs (if not already performed in ER):
[ ] ECG
[ ] CBC
[ ] BLP
[ ] Serum calcium
[ ] Serum magnesium
[ ] Serum ethanol level
[ ] Serum and urine toxicology screen
[ ] Serum ammonia level
Anticonvulsant levels: [ ] phenytoin [ ] carbamazepine [ ] valproic acid [ ] phenobarbital

17. Other (do not order if already performed in ER):

[ ] Head CT scan without contrast.
[ ] EEG (routine)
[ ] EEG (stat) }
} Diagnosis: _seizures_____________________
}

18. Notify MD if:
T > 101° F, BP > 170/110 or < 90/60, pulse > 130 or < 40, pulse ox. < 90%, seizures, worsening mental status

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Signature

Seizures

1. Types of seizures

A seizure is a sudden alteration in behavior believed to be caused by paroxysmal neuronal discharges. The most common seizure types in adults are:
1) Generalized motor seizures are caused by discharges over much of the brain. A convulsion is the obvious symptom.
2) Complex partial seizures are usually caused by discharges in the temporal or frontal lobes. The symptom is sudden alteration of consciousness and behavior, but without generalized convulsive activity.
3) Simple partial seizures are the least common, and can be caused by discharges in many parts of cerebral cortex. The symptom is highly variable and depends on the part of cerebral cortex affected. Simple partial motor seizures, which cause focal convulsions of a single limb, but with preservation of consciousness, are fairly common.
4) Partial seizures with secondary generalization are very common.
Other seizure types are uncommon in adults (see International Leage Against Epilepsy Classification of Seizures).

Seizures are to be distinguished from:
1) Syncope, caused by low blood flow to brain, usually due to sudden drops in blood pressure.
2) Pseudoseizures. Pseudoseizures are usually caused by conversion disorder, and are thought to be a behavioral manifestation of an inner psychological conflict.

Seizures are a common medical emergency, especially if they are prolonged or occur repeatedly. Prolonged or repeated seizures may be generalized motor, complex partial, or simple partial, and can be classified as
1) Status epilepticus. A single prolonged seizure, or seizures that occur so frequently that consciousness is not regained. Generalized motor status epilepticus is a true medical emergency and should be treated promptly.
2) Frequent seizures. Several or many seizures, with recovery in between. The urgency of the situation is variable.
3) Single seizures. Usually this is not an urgent indication for treatment.

2. Seizure decision tree

A. Is this a generalized convulsive seizure?
    NO, it is a complex partial or simple partial seizure --> See options for non-urgent treatment of seizures. Reassess frequently.
    YES continue below.
B. Has it lasted more than 5 minutes?
    NO continue below.
    YES --> Treat for status epilepticus
C. Has there been a recent previous seizure without recovery?
    NO ---> See options for non-urgent treatment of seizures. Reassess frequently.
    YES --> Treat for status epilepticus

3. Treatment of status epilepticus

Status epilepticus has a high mortality--about 30% in the first 30 days after status epilepticus, if it is prolonged more than one hour. Some of the morbidity and mortality is due to systemic problems such as hyperthermia, rhabdomyolysis, or acidosis and the various problems these can cause. Of course, the convulsion can be prevented by muscular paralysis, but to treat with paralytic agents is almost always an error, because the paroxysmal electrical activity of brain continues, and can cause brain damage. Treatment involves a quick assessment for likely cause of the seizures, followed by intravenous administration of antiepileptic drugs.

Time table for treatment of status epilepticus

a. 0-10 min, do ABC's:

O₂ by nasal cannula. Intubate if necessary.
Establish IV access.
Draw glucose, serum chemistries, CBC, toxicology screen.
Draw antiepileptic drug levels if patient is known to be treated with them.
Thiamine (100 mg) then glucose (50 ml of 50%) if hypoglycemia suspected.

b. 10-20 min, administer a benzodiazepine drug:

Lorazepam (0.1 mg/kg at 2 mg/min IV) or diazepam (0.2 mg/kg at 5 mg/min IV). Both drugs act quickly, diazepam slightly faster. Diazepam redistributes quickly, and its effective duration of action may be only 5-10 min. May repeat diazepam dose if necessary. If diazepam is used, phenytoin (or fosphenytoin) should next be given to prevent recurrence of seizures. The effective duration of action of lorazepam is 8-10 hours, and is recommended for initial treatment of status epilepticus.

c. 20-60 min, administer fosphenytoin or phenytoin

Fosphenytoin Water-soluble phosphate pro-drug of phenytoin. Replaces IV phenytoin, which is highly alkaline (pH 12) and dissolved in 40% propylene glycol/10% ethanol. Dose using "phenytoin equivalents". (Its molecular weight is 1.5 times that of phenytoin.) Can be used IM. Can be given at a rate of 150 mg/min IV. Hypotension and cardiac arrhythmias less common than with phenytoin.

Phenytoin In adults give 18 mg/kg no faster than 50 mg/min IV. Monitor ECG and BP during infusion. Do not use glucose-containing IV solution. Purge with NS before infusion. Do not give phenytoin IM. Ensure adequate IV access because local infiltration of phenytoin can cause necrosis.

d. >60 min

Administer additional doses of fosphenytoin or phenytoin up to a maximum of 30 mg/kg.
Administer phenobarbital (20 mg/kg at 100 mg/min IV). Assisted ventilation will usually be required.

e. If seizures persist:

Pentobarbital infusion. 5 mg/kg load, then 1-3 mg/kg/hr. Must use EEG monitoring, goal is to titrate to EEG burst-suppression. Avoid hypotension if possible, but fluids and pressors may be needed.
Midazolam drip. Use with EEG monitoring if possible, titrate infusion to eliminate electrographic seizures. 200 micrograms/kg as a slow IV bolus, followed by 0.75 to 10 micrograms/kg/min continuous infusion. In the most refractory cases more than 10 micrograms/kg/min may be needed. Hypotension is uncommon but may occur.
Diazepam drip. Used infrequently.
Lidocaine drip. May cause seizures in high doses.
General anesthesia with halogenated anesthetic.
Do not merely paralyze the patient.

References

Barry E, Hauser WA (1992) Status epilepticus: the interaction of epilepsy and acute brain disease. Neurology 43: 1473-1478.
Parent JM, Lowenstein DH (1994) Treatment of refractory generalized status epilepticus with continuous infusion of midazolam. Neurology 44: 1837-1840.
Wilder BJ (ed.) The use of parenteral antiepileptic drugs & the role for fosphenytoin. Neurology 46 suppl. 1.
Working Group on Status Epilepticus (1993) Treatment of status epilepticus: recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA 270: 854-859.

4. Options for urgent treatment of seizures

Treatment of partial status epilepticus or convulsive seizures with recovery between them is urgent, but it is not the emergency generalized convulsive status epilepticus is. Intravenous drugs as used for status epilepticus are also useful here, except for diazepam. Diazepam can terminate a prolonged seizure, but is too short-acting to prevent a second from occurring. The most useful intravenous drugs are lorazepam, fosphenytoin, and intravenous valproate. Heavily sedating drugs like phenobarbital and midazolam can be used, but drug-induced coma and assisted ventilation are risky. Because the condition is less urgent, oral medications may be useful, but they take longer to act than intravenous drugs.

Medications given by mouth or enterally through an NG tube that are often useful for acute treatment include:

Phenytoin Give 300 milligrams hourly until a full loading dose is achieved. Dilantin is especially useful because of prolonged absorption.
Phenobarbital This has a very long half life, and a full loading dose can be given all at once by mouth. It will cause considerable sedation.
Carbamazepine This drug is very effective, but has a short half-life and cannot be easily given as a loading dose. 200 to 400 mg TID can be used as a starting dose.
Trileptal Similar to carbamazepine, but has a longer half life, and can be started at a dose of 300 mg TID.
Valproic acid Has a relatively short half life, but can be started at a dose of 250 mg TID.
Topirimate Occasionally useful in the patient with refractory seizures. Not tolerated by patients who are awake and alert.
Felbamate Occasionally useful for refractory seizures at 300 mg TID to start, increasing to 600 mg TID. The patient must be warned of the risk of aplastic anemia or fatal hepatis. The manufacturer recommends obtaining a written informed consent.
Zonisamide Useful especially for myoclonus.

Other oral medications simply take weeks to start and are not often useful acutely.

Lamotrigine
Topirimate