Manage Acute Seizures

Dr Al Buick
Royal Devon and Exeter Hospital
View presentation
www.meducation.net/media_files/29625
The Management of Acute Fits

Outline
• What do we mean by acute fits?
• Different types of seizure
• Causes of seizures
• Management of acute seizures
• Complications of seizures
• Some quick cases
Meducation The Medical Education Network www.meducation.net

Definitions – what does it all mean!
Acute Fits EpilepsyStatus
Epilepticus

Epilepticus
What we might also call an acute seizure

A prolonged seizure or seizures repeated
frequently enough to prevent recovery
between episodes occurring over a period
of 20-30 minutes.
Epilepticus

Recurrent episodes of intermittent
brain dysfunction due to a sudden,
disorderly, and excessive neuronal
discharge. This can manifest as a
seizure.
Epilepticus

Different types of seizure
Seizures
Partial Generalised
Simple Complex
Absence Myoclonic Tonic-Clonic Tonic Atonic

So what can cause a seizure?

Causes of seizures- Intracranial
Underlying brain pathology
• Underlying brain
abnormality
• Raised intracranial
pressure
• Cerebral tumour
• Cerebral oedema
• Pregnant – Ecampsia
• Stroke
• Thrombo-embolic
• Haemorrhagic
• Brain infections
GIANT CELL TUMOR,
14 MONTHS WITH SEIZURES

Extracranial- We could all suffer fits given the right
situation
Pyrexia
Biochemical
• Sodium, Glucose
• Calcium, magnesium
• Urate
Hypoxia – (e.g. Carbon monoxide poisoning)
Causes of seizures- Extracranial
Drugs
• Prescribed
• Recreational
• Withdrawal

Management of seizures
You are the F1 on call and it is 3am. You receive a
bleep from one of the wards….
“Could you come and see this patient….. they are
having fits and we don’t know what to do….. Please
come quickly…”

Management
A
B
C
D
Airway
Breathing
Circulation
Disability
Is their airway patent?
Give airway
management if needed

Management
A
B
C
D
Airway
Breathing
Circulation
Disability
• What is the
respiratory rate?
• What are their
oxygen saturations
• Give oxygen if
needed

Management
A
B
C
D
Airway
Breathing
Circulation
Disability
• Heart rate
• Blood pressure
• Peripheral perfusion
Capillary refill time

Management
A
B
C
D
Airway
Breathing
Circulation
Disability
• Other signs
•? Head injury
•? Bleeding
• ? Sign of infection
Don’t
Forget
Glucose

Management of fits – Stepwise appraoch
Initial A,B,C,D
Benzodiazepi
ne
Phenytoin
Paralysis and
ventilation
Start treating
underlying
cause

Benzodiazepine
If fit does not resolve after a few minutes consider
giving a benzodiazepine
Action
 Enhance effect of GABA which is the main inhibiting
neurotransmitter
 Therefore reduce the excessive neuronal discharge

Benzodiazepine
Side effects to be aware of
 Sedating and muscle-relaxing action
 Suppressed breathing
 Hypotension (worse with IV)
 Reduced conscious level
 Nausea
 Euphoria

Benzodiazepine
Drug Peak onset Half life
Midazolam About 1 hour Short (3 hours)
Lorazepam About 3 hours Medium (15 hours)
Diazepam About 2 hours Long (30+ hours)
Chlodiazepoxide About 3 hours Long (30+ hours)

Phenytion
Works on sodium channels
 Blocks voltage-sensitive sodium channels in neurons
 Delay in neuronal electrical recovery from
inactivation
 Inhibitory effect is dependent on the voltage and
frequency of neural cell firing by selectively blocks
neurons that are firing at high frequency

Phenytion
Pharmicokinetics
 Mainly hepatic break down
 Zero order kinetics

Phenytion
Side effects
Beware of toxicity as zero order
 Arrhythmias (it is a class 1b antiarrhyhmic)
 Bradycardia
 Hypotension
Bradykinesia, ataxia
 Sedation, confusion
 Teratogenicity

Paralysis and ventilation
If seizure not managed by the initial methods
Amy need to consider paralysis and ventilation
 Should be done in ITU
 Expert help required

Complications of Seizures
SUDEP - Sudden Unexpected Death in Epilepsy
Brain injury
Physical Injury
• Direct from fit – Tongue biting fitting
• Driving?

Case 1
A 21 year old diabetic girl presents to the
emergency department having been found out
shopping on a Saturday morning. She was
reported previously well by her friends and had
even been out for some drinks the night before.
Her friends tell you she was acting strange and
then collapsed. She not not very responsive and
10 minutes later she started fitting.
What else do you want to know and what are you going
to do?

Case 2
A 84 year old woman is brought in by ambulance
having been found at home by her son on the
floor. She was unresponsive and has been fitting
on an off since she had been found.
Her son reports she is normally fit and well and
only has bad arthritis, recently given “some sort of
patch of the pain”
to do?

Case 3
A 20 year old motorcyclist was found having
crashed in to a wall. He was brought in by air
ambulance. He is barely conscious but responds
to pain.
He is fitting every 5 minutes and has been for 45
minute since he was found.
to do?

Manage Acute Seizures

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