- Clear surrounding area - Put into recovery position once it is over - Pbserve for signs of breathing, aspiration, injury

- if not confused or injured, no immediate action required Seek medical attention -> Investigation - If confused/injured: wait with them and reassure them; do not attempt to give fluids/food/drug - Call ambulance

- If they recover from seizures: wait with them until fully recovered, may be worth noting any triggers, patterns etc, ? Consider meds review - If they don't: Medical emergency

- Lorazepam bolus (4mg iv) - repeat once if necessary, after 10 mins

- If seizures continue or >30 mins despite Rx then general anaesthesia is given (thiopentone iv bolus then infusion) - artificial ventilation is likely to be necessary - the anaesthetic dose shouldn't be tapered until >12 hrs after last seizure - EEG monitoring must be done as ventilated pt will be paralysed with muscle relaxants so may not have observable seizures

Anti-epileptic drugs (AEDs) - generally after 2ndry seizure - Monotherapy where possible - review medication: aim to use minimum dose to maintain control and ideally seizure-free - It may be possible for patients to come off medication (epilepsy remits in 70%) - obviously they need to have been well-controlled and seizure free for some time - Important to consider the implications for the patient - depends on individual, their lifestyle, needs etc. i.e. someone who relies on driving may not wish to risk losing their license etc.

Paeds: Epilepsy (DrClarke) Management Flashcards by tish bullman

Seizure

Clear surrounding area
Put into recovery position once it is over
Pbserve for signs of breathing, aspiration, injury

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Seizure

if not confused or injured, no immediate action required Seek medical attention -> Investigation
If confused/injured: wait with them and reassure them; do not attempt to give fluids/food/drug
Call ambulance

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Seizure

If they recover from seizures: wait with them until fully recovered, may be worth noting any triggers, patterns etc, ? Consider meds review
If they don’t: Medical emergency

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Seizure >5-10 minutes: Immediate treatment

Treat and investigate source.
MEDICAL EMERGENCY:
-Immediate ->resuscitate measures ABC: airway maintained, oxygen given
- Control of seizure-anticonvulsant medication given.
- Identification of underlying cause - ?hypoglycaemia, electrolyte/cardiac/biochemical monitoring

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Medical management 4 stages

Premonitory phase
Early status
Established status
Refractory status

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Premonitory phase

Diazepam (10-20mg iv or rectally) - can be repeated once 15 mins later if status still dangerous OR iv bolus clonazepam (1-2mg)

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Early status

Lorazepam bolus (4mg iv) - repeat once if necessary, after 10 mins

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Established status

Phenobarbitone bolus (10mg/kg 100mg/min) and/or phenytoin infusion (15mg/kg 50mg/min-ECG monitoring) - small risk of respiratory depression but can help obtain control

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Refractory status

If seizures continue or >30 mins despite Rx then general anaesthesia is given (thiopentone iv bolus then infusion) - artificial ventilation is likely to be necessary - the anaesthetic dose shouldn’t be tapered until >12 hrs after last seizure - EEG monitoring must be done as ventilated pt will be paralysed with muscle relaxants so may not have observable seizures

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Long term management

Anti-epileptic drugs (AEDs) - generally after 2ndry seizure

Monotherapy where possible
review medication: aim to use minimum dose to maintain control and ideally seizure-free
It may be possible for patients to come off medication (epilepsy remits in 70%) - obviously they need to have been well-controlled and seizure free for some time
Important to consider the implications for the patient - depends on individual, their lifestyle, needs etc. i.e. someone who relies on driving may not wish to risk losing their license etc.

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3 basic mechanisms for the action of anti-epileptic drugs:

Suppression of sodium influx
Suppression of calcium influx
Potentiation of gamma-aminobutyric Acid (GABA)

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Suppression of sodium influx process

The AED binds to sodium channels when they are in the inactive state, thus prolonging the inactive state ↓ ability of neurons to fire at high frequency. Seizures that depend on high frequency discharge are therefore suppressed.

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Examples of drugs that suppresses of sodium influx and which seizures they are used in

Carbamazepine, phenytoin & lamotrigine exert their main action in this way & are effective in limiting the spread of a discharge from a focusRx of partial & 2o generalised seizures.

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SUPPRESSION OF CALCIUM INFLUX.

The AED acts by inhibiting influx of calcium ions through T-type Ca channels. These calcium channels generate T-currents which usually play a minimal role in action potential generation, but in some neurons in the hypothalamus, T-currents cause action potentials. Absence seizures are caused by ↑ firing of hypothalamic neurons

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examples of drugs that suppress calcium infux

this mechanism are preferred for absence seizures. Sodium valproate & ethosuximide act in this way.

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POTENTIATION OF GAMMA-AMINOBUTYRIC ACID (GABA).

GABA is an inhibitory neurotransmitter that is widely distributed in the brain &amp; causes a general ↓ in neuronal excitation
drug examples:
- Barbiturates e.g. phenobarbital
- gabapentin
- vigabatrin
- Benzodiazepines e.g. diazepam

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Benzodiazepines

examples and action

e.g. diazepam

potentiate GABA, either by acting directly on GABA receptors

by promoting GABA release examples

gabapentin

by inhibiting the enzyme that degrades GABA example

vigabatrin

Benzodiazepines

diazepam: IV/rectal to control individual fits) & clonazepam (orally for prophylaxis usually taken with other drug) ↑ affinity of GABA for its receptor

VALPROATE

Indication
recommended for which seizure type
concerns

1st line if unable to classify type of epilepsy
Broad spectrum
Recommended esp. for generalised onset seizures
Fewer pharmacokinetic problems
Fewer adverse effects
CONCERNS – foetal damage

CARBAMAZEPINE

Indication
recommended for which seizure type
concerns/interactions

• Good general choice
• Recomm. esp. for partial seizures
• But acts on P450 system - interacts with OCP etc many drug
interactions
• Fewer side-effects than phenytoin
• Monitoring of levels helps determine optimum dose

PHENYTOIN

Indication
recommended for which seizure type
concerns/interactions

Narrow therapeutic window
Significant variation in individual response
Many drug interactions
Zero order kinetics
Monitoring of levels ESSENTIAL
Avoid where possible

LAMOTRIGINE

Best-established of the newer generation drugs
Broad spectrum
Works for almost all forms of epilepsy
Reasonable safety profile but:
Severe skin reactions in children
Blood disorders
Interaction with valproate
Good choice for girls (i.e. re: pregnancy etc)

SURGERY

Surgery is an option in pts where there is a definite site of seizure onset with highly localised focus. Occasionally it can be used to reduce symptoms is patients with intractable epilepsy.

surgical management only beneficial in

focus – surgery can only help where there is a specific site at which seizures always start • nature – surgery always carries risk therefore the benefits need to be significant – usually patients with frequent, severe seizures, impacting on their QoL, despite treatment • area – tests will be performed to accurately assess the area of brain involved and its function

Procedures available

1. Selective amygdalo hippocampectomy 2. Temporal lobectomy 3. Sub-pial resection 4. Hemispherectomy 5. Corpus callosotomy 6. Removal of a lesion e.g. tumour, cyst

Selective amygdalo hippocampectomy

hippocampectomy | Removal of 2 structures in temporal lobe which are the sites of seizure activity. Sometimes only hippocampus is removed.

Temporal lobectomy

A larger part of the temporal lobe is removed - usually the right side as the left side of the temporal lobe controls speech

Sub-pial resection

Fine cuts are made in the motor areas of the brain -they don’t affect motor function but do prevent the spread of seizures

Hemispherectomy

Sometimes used to treat very severe epilepsy in children with damage to one whole side of the brain - the damaged side of the brain is removed

Corpus callosotomy

Also sometimes used to treat children with very severe epilepsy (Atonic drop attacks) - the operation involves sectioning the fibres that connect the two halves of the brain

COMPLICATIONS OF seizures:

1. Status epilepticus 2. Injruy 3. Aspiration 4. permanent brain damage/difficulty with learning 5. Anti-epileptics can cause birth defects

Status Epilepticus

(recurring seizures, w/o pt regaining consciousness b/t attacks, for 30 mins or more. May permanent brain damage & death due to prolonged hypoxia) A MEDICAL EMERGENCY!

Lifestyle and social issues

1. Driving 2. employment 3. Leisure 4. Pregnancy 5. Other

Driving

must inform DVLA when diagnosed. Generally 1 year ban following a seizure (regardless of whether it occurs in the day or at night). Pt is then reviewed, & if they have been seizure free & are believed to be under good control then they will be allowed to drive again. If a person only has night seizures, they may be allowed to drive again even if they continue to have seizures. If a pt is withdrawing from AEDs, they are advised not to drive during the withdrawal period or for the next 6 months and if they do have a seizure, they will be banned for 1 yr again.

Employment –

UK Disability Discrimination Act – only the Armed Forces are completely banned (by law). Other jobs may be restricted due to health & safety regulations (e.g. pilots, drivers, work that could be hazardous to the person or risk harm to others etc) – advisable to disclose epilepsy although there is no legal obligation to do so – if it is not disclosed, employers will not be liable for any harm should the employee have a seizure

• Leisure –

being active does not provoke seizures and may even be beneficial – safety is the important consideration – people with epilepsy should never swim alone (or be around water), should not perform activities e.g. climbing while epilepsy is uncontrolled – most activities are ok as long as person is sensible & always has a companion who knows what to do should they have a seizure – potential hazards include television (photosensitive epilepsy), computers (rarely), video games, theme parks, night clubs and of course water, heights etc

Pregnancy –

many AEDs reduce the efficiency of the pill need to consider type of medication & potentially other methods of contraception – also, when considering pregnancy, beneficial to have epilepsy under control before becoming pregnant (ideally) – need to think about medication/risks of malformation (give oral vit K a wk before deliver to preventneonatal haemorrhage causd by inhibition of transplacental transport) – after birth breastfeeding is usually not a problem

• Other –

ree prescription charges – exemption certificate FP92A (England) Counselling – diagnosis of epilepsy can have substantial psychological impact – important to discuss with pt & family Alcohol can provoke seizures so it may be necessary to provide advice and support on this Epileptics shouldn’t be alone e.g. when having a bath, bathing/looking after a baby so it really can impact greatly upon everyday life