Emergency And general bedside management of the Epilepsy in the Casualty and inpatient patients.

1. Q.) Clinical bedside management of epilepsy.
Answer- Epilepsy is diagnosed when there are recurrent seizures due to a chronic,
underlying cause. A Seizure is a paroxysmal event due to abnormal excessive or synchronous
neuronal activity in the brain.
Clinical Evaluation- Diagnosis is based solely on clinical ground, hence careful history
taking is important. General examination for the infection, trauma, toxins, systemic illness &
neuro-cutaneous abnormalities should be done.
Laboratory Evaluation- R/M/E for common metabolic abnormalities viz. electrolyte
abnormalities, Glucose, Ca++, Mg++,Hepatic & Renal disease. Lumber puncture(Meningitis,
Encephalitis, HIV), Electroencephalography, Brain imaging(CT-Scan, MRI).
Clinical Bedside Management-
Therapeutic goal is complete cessation of seizures without S/E using a monotherapy and a
dosing schedule that is easy for patient to follow.
Acute Management-
 Pt should be placed in Left lateral position to prevent aspiration pneumonia.
 Tongue blades or other object should not be placed or forced between clenched teeths.
 Oxygen via mask, Adequate O2 saturation.
 Reverse metabolic disorder (If any).(viz. hypoglycemia, hyponatremia, hypocalcemia
etc).
 Treatment of status epilepticus
Long Term management-
 Treatment of underlying conditions, Avoidance of precipitants, prophylactic therapy
with anti-epileptic medications or surgery, and address various psychological and
social issues.
Anti-Epileptic drugs- DoC of AEDs depends upon variety of factors including seizure types,
dosing schedule, and potential S/E.
Phenytoin- It is diphenyl hydantoin used in tonic-clonic & Focal onset seizure. given in a
dose of 300-400mg/day in 2-4 divided doses. Dizziness, DSiplopia, Ataxia, Incoordination,
Gum hyperplasia, Lymphadenopathy Hirsutism, Osteomalacia rae its major limitations. Its
level are altered by some drugs like Isoniazis, Sulpha-drugs, & other CNS drugs.
Carbamazepine- At a dose of 600-1800 mg/ dayin 2-4 divided doses it act as first line
therapy in Focal onset epilepsy & widely used in Tonic-Clonic seizure, Ataxia, Dizziness,

2. Diplopia, Vertigo, Leukopenia, GI symptoms are its usual S/E. Drug widely interacts with
various agent like enzyme inducing drugs, erythromycin, isoniazid, cimetidine etc.
Valporic Acid- Dose of 750-2000 mg/day in 2-4 divided doses. Used in Tonic-Clonic,
Absence, Atypical, Myoclonic, & Atonic seizure. S/E might be ataxia,Sedation, Tremor,
Hepatotoxicity, Weight gain, Alopecia, Hyperammonia. It may get decreased by enzyme
inducing drugs.
Lamotrigine- Dose of 150-500 mg/day in 2 divided doses. Used in Tonic-Clonic, Focal-
onset, Lennox-Gastaut syndromme Absence, Atypical, Myoclonic, & Atonic seizure. S/E
might be Dizziness, Diplopia, Sedation, Headache, SJS, Skin rashes. It may get decreased by
enzyme inducing drugs & OCPs.
Ethosuximide- Used in absence seizure only at the dose of 750-1250 mg/day in 2-4 divided
doses, Ataxia, Lethargy, Headache, Bone marrow suppression are its major S/E. Level of
drugs are increased with Valporic Acid.
Phenobarbital- Used in tonic-clonic, Focxal-Onset epilepsy at dose of 60-180mg/day in 4
divided doses. Sedation, ataxia,Sedation, Tremor, Hepatotoxicity, Weight gain, Alopecia,
Decreased libido etc are its S/E. might have increased activity with other drugs.
Levetiraacetam- At a dose of 1-3 gm it is used in Focal-Onset type of epilepsy.Sedation,
Fatigue, Incoordinbation , mood changes are its common S/E.It is having no known
interacrtions.
Lacosamide is used in Focal onset seizure at dose of 200-400 mg/day in BD dose , Cardiac
arrest may occur, Ataxia, Diplopia.
Gabapentin- 900-2400 mg/ day in TDS dose.
Topiramate- 200-400 mg BiD.
Clonazepam, Felbamate, Tiagabine, Zonisamide, Oxycarbazine etc.
Note - If drug is ineffective, adjust maximum tolerated dose based on clinical outcome rather
then therapeutic range.if still unsuccessful then add another drug, Patient with temporal lobe
epilepsy are refractory by drugs hence surgical intervention is required.
Patient counselling-
 Reduce noises and other precipitants.
 Avoid Bright, Flashing, or Flourescent Lights
 Adequate Sleep
 Exercise regularly
 Balanced Diet
 Avoid Stress, Anxiety, Depression
 Limit or avoid alcohol intake.

3. Nursing Care-
1. Administer anticonvulsant therapy as prescribed.
2. Monitor the patient continuously during seizures.
3. If the patient is taking antiseizure medications, constantly monitor for toxic signs and
symptoms such as slurred speech, ataxia, lethary, and dizziness.
4. Monitor the patient’s compliance with anticonvulsant drug therapy.
5. Loosen any tight clothing, and place something flat and soft, such as pillow, jacket, or
hand, under his head.
6. Avoid any forcing anything into the patient’s mouth if his teeth is clenched.
7. Avoid using tongue blade or spoon during attacks which could lacerate the mouth and
lips of displace teeth, precipitating respiratory distress.
8. Protect the patient’s tongue, if his mouth is open, by placing a soft object between his
teeth.
9. Turn the patient’s head to the side to provide an open airway.
References-
1) Longo, Fauci, Kasper et.al, Harrison's Manual of medicine, Mc Graw Hill education
publication, 18th edition. page -1199-1212
2) https://www.ncbi.nlm.nih.gov
3) https://www.epilepsysociety.org.uk