EPILEPSY Refresher

What is seizure

1. Seizures are episodes of brain malfunction due to abnormal electrical discharges
1. Seizures can be classified as generalized or partial according to the clinical presentation
2. Our focus will be only on GTCS

What is epilepsy

The condition in which people experience recurrent (at least twice), unprovoked seizures

Causes

2.       Complications during childbirth

3.       Head injury

4.       Brain infections

a.       Meningitis, encephalitis, cerebral malaria

5.       Neurocysticercosis (tape worm)

6.       Genetic, only in some cases

7.       Some epilepsy has no known cause

8.       Stroke

Types of Seizure

1. Genearlized Tonic Clonic
2. Partial Serizure
3. Complexpartial
4. Absence
5. Febrile convulsions

Symptoms of GTCS

1.       Preictal Stage/ postictal stage

2.       Loss of counsciousness

3.       Tonic clonic contraction of whole body

4.       Uprolling of eyes

5.       Clinching of teeth/ tounge bite

6.       Loss of bowel/bladder

7.       Injury

Why should we treat epilepsy

1. Epilepsy is common (prevalence is 0.8-1.2%)
2. Epilepsy is life threatening
3. Each seizure causes brain injury
4. People with epilepsy are stigmatized and excluded
1.  Some children with epilepsy are not allowed to go to school
2. People don’t get married
3. Treatment is simple, inexpensive and effective
4.  70% can be seizure-free for life after 2 years of treatment
   
   

Pseudoseizure (PNES)       Seizure

1. Duration:
1. Minutes to hrs                      Seconds to Minutess
2.  Auras:
1. Absent                                  Present
3.  Injury:
1. None or minor                      Serious injury may be present
4.  Always occurs in presence      May occur alone or in presence of  someone else                         of someone else
5. Postictal confusion:
1. Absent                                   Present                        
6. Incontinence of stool and urine

                                                               i.      Absent                                      May be present

7.       Total loss of conciousness:

                                                               i.      May not be present                   Always Present

8.       Frothing/ Tounge bite:

                                                               i.      Not present                                May be present

9.       Possessions/ Asking for water:

                                                               i.      May be present                          Always absent

Management of acute stage

1. Airway
2. Breathing
3. Circulation

DO NOT leave the person alone

Place in recovery position

Make sure NOTHING is in the mouth

Measure and document vitals

1.       Blood Pressure

2.       Temperature

3.       Respiratory rate

a.       These must be measured accurately and documented

b.       In particular, respiratory rate should be counted. You may be using drugs that cause respiratory depression

Rule out other causes

1. Organic:
1. Hypoglycemia
2. Meningitis
3. Head trauma

2.       Substance abuse:

1. Alcohol and Benzodiazepams

3.       Eclampsia

4.       Febrile seizure

Manage Seizure

1. Start intravenous fluids
1.  IV Glucose slowly, 30 drops/minute
2. Adults: Give IV Diazepam 10mg slowly OR IV Lorazepam 4mg  slowly
2. Children: Give diazepam IV 0.2 -0.5 mg/kg slowly (maximum 10 mg) or lorazepam IV 0.1 mg/kg(maximum 4mg), if available

If IV line cannot be made

1. If you cannot place an intravenous cannula
1. DO NOT GIVE IM DIAZEPAM, it is poorly and erratically absorbed
2. Give rectal diazepam

                                                               i.      Use the rectal formulation if available

                                                             ii.      If the rectal formulation is not available, the IV formulation can be used

                                                            iii.      Adults: 10mg

                                                            iv.      Children: 0.2 – 0.5 mg/kg (maximum 10mg)

2. Do not forget to place an IV cannula after the seizure has stopped

If seizure does not stop

1. It could be Status epilepticus
2. Status epilepticus is defined as:
1. More than 30 minutes of continuous seizure activity OR
2. Two or more sequential seizures without full recovery of consciousness between seizures  
3. If the seizure does not stop 10 minutes after the first dose of diazepam, give a second dose of the same amount
4. Refer the person to hospital as this is an emergency
5. Do not give more than 2 doses of diazepam

Starting antiepileptic therapy

1.       Seizure diary

2.       Do not treat single episode of seizure with prophylactic therapy

Carbamazepine

1. MOA: Stablizes Na channels
2. Metabolism:
1. Liver
2. Autoinduction
3. T ½ 25 to 65hrs(initially) 10 to 20 hrs (later)
4. Elimination : Urine

Carbamazepine

1.       In child

1. Starting dose: 5 mg / kg / day in divided dose 12hrly
2. Maintenance dose: 10 – 30 mg / kg / day

2.       In adult

1. Starting dose: 100 -200 mg / day
2. Maintenance dose: 400 – 1200 mg / day

Side Effects:

1. Ataxia
2. Dizziness
3. Nausea and Vomiting
4. Hypersensitivity reactions
5. Aplastic anemia and bone marrow suppression

Phenobarbitone

1. MOA: Acts on GABA
2. Metabolism:
1. Liver
2. Enzyme Inducer
3. T ½  : 50 to 140hr
4. Elimination : Urine 

5.       In child

1. Starting dose: 2 – 3 mg / kg / day
2. Maintenance dose: 2 – 6 mg / kg / day
3. Initiate with 2 mg / kg / day for 2 weeks. If poor response increase the dose to 3 mg / kg / day for 2 months. If seizures persist, increase the dose to maximum of 6 mg / kg / day.

6.       In adult

1. Starting dose: 60 mg / day
2. Maintenance dose: 60 – 180 mg / day
3. Initiate with 1 mg / kg / day (60 mg tablet) for 2 weeks. If poor response, increase to 2 mg / kg / day (120 mg) for 2 months. If seizures persist, increase the dose to 3 mg / kg / day (180 mg)

Side Effects:

1.       Ataxia

2.       Drowsiness

3.       Nausea and Vomiting

4.       Behavioural Problems

5.       Headache

Phenytoin

1. MOA: Acts on Na clannel
2. Metabolism:
1. Liver
2. Enzyme inducer
3. T ½ : 22hrs
4. Elimination : Urine
5. In child
1. Starting dose: 3-4 mg \kg \day
2. Maintenance dose: 3-8 mg \kg\day (maximum 300 mg \daily)
3. In children give twice daily.
6. In adult
1. Starting dose: 150-200mg \day
2. Maintenance dose: 200-400 mg \day

Side Effects

1.       Drowsiness

2.       Gum Hyperplasia

3.       Ataxia/  slurred speech

4.       GI disturbances

5.       Cardiac problems in high doses

6.       Rashes

Key points

1. Taking the medication as prescribed is essential
2. Consult your healthcare provider in case of recurrence of seizures or side-effects
3. Consider stopping treatment if there have been no seizures for two years.
1. Explain that there is a risk of seizure recurrence after stopping the medication (10-20%).
2. It should be done in consultation with family
4.  For women of child bearing age
1. Give folic acid
2. Breastfeeding is safe
5. Missed doses?
6. People with epilepsy can do most jobs but should avoid
1. Heavy machinery
2. High places
3. Collecting water from open bodies of water
4. People with epilepsy should avoid swimming alone and cooking on open fires
7. People with epilepsy should avoid
1. Excessive alcohol
2. Recreational drugs
3. Sleep deprivation
4. Flashing lights
5. Fasting

Follow ups

1. Follow up
1.  once a month for the first 3 months
2.  then once every 3 months
2. Explain that the person can come in whenever needed and that the person should come in immediately if there is another seizure