1. A seizure is caused by abnormal electrical activity in the brain, and epilepsy is recurrent seizures. Common triggers include sleep deprivation, alcohol withdrawal, infections, and flashing lights. 2. Emergency management of seizures focuses on stabilizing the airway and maintaining breathing and circulation. The patient should be placed in the lateral decubitus position with oxygen to prevent hypoxia. 3. For status epilepticus, which is prolonged or repeated seizures, intravenous benzodiazepines like diazepam or lorazepam are given followed by phenytoin, fosphenytoin, or phenobarbital if seizures continue. Intubation and ventilation may be needed along with general anesthesia if seizures

1. Acute Management of Seizure
Sunil Kumar Daha

2. Seizure
• A seizure is any abnormal clinical event caused
by an abnormal electrical discharge in the brain
• Epilepsy is the tendency to have recurrent
seizures
(It is symptom of brain disease rather than a disease itself)

5. • Sleep deprivation
• Alcohol (particularly withdrawal)
• Recreational drug misuse
• Physical and mental exhaustion
• Flickering lights, including TV and computer screens
(primary generalized epilepsies only)
• Intercurrent infections and metabolic disturbances
• Uncommonly: loud noises, music, reading, hot baths
Trigger factors for seizures

7. Emergency Management of Seizure

8. • Initially primary survey
– A: Airway and C-spine
– B: Breathing
– C: Circulation
– D: Disability(AVPU/ GCS) and pupil
– E: Exposure
• Secondary survey

9. Stabilization of Airway is Important!
• Oxygen should be administered by nasal cannula or
facemask.
• An oropharyngeal airway kit and bag valve mask
should be ready at bedside,
• IV line should be established.

10. If the patient is actively seizing…
• Placed in a lateral decubitus position with the
head positioned at a 30-degree angle to minimize
aspiration,
• Seizure precautions:
– Placing the bed in the lowest position,
– Any objects that can injure the patient should be
removed
– Making sure that oropharyngeal airway kit and BVM,
oxygen, and suction are available at bedside.

11. Immediate care of seizures
• Little can or need be done for a person during
the time a major seizure is occurring except
first aid and commonsense maneuvers to limit
damage or secondary complications
• Consists of
– First Aid
– Immediate Medical Care

12. First Aid
• Is to be given by relatives or witnesses
• Move person away from danger (fire, water,
machinery, furniture)
• After convulsions cease, turn into ‘recovery’
position (semi-prone)
• Ensure airway is clear, but do NOT insert anything
in mouth (tongue-biting occurs at seizure onset and
cannot be prevented by observers)
• If convulsions continue for more than 5 minutes or
recur without person regaining consciousness,
summon urgent medical attention
• Do not leave person alone until fully recovered
(drowsiness and confusion can persist for up to 1
hour)

13. Immediate medical care
• Ensure airway is patent
• Give oxygen to offset cerebral hypoxia
• Give intravenous anticonvulsant (e.g. diazepam 10
mg) ONLY if convulsions are continuous or repeated
(if so, manage as for status epilepticus)
• Take blood for anticonvulsant levels (if known
epileptic)
• Investigate cause

14. Anticonvulsant therapy
 Drug treatment should be considered after more than
one episode of seizure has occurred.
 Of patients whose epilepsy is controllable, only a
single drug is necessary in 80%, providing the choice
of agent is appropriate and dosage correct.
 The combination of more than two drugs is seldom
necessary.
 Dose regimens should be kept as simple as possible
to promote compliance

16. Guidelines for anticonvulsant therapy
• Start with one first-line drug
• Start at a low dose; gradually increase dose until effective control
of seizures is achieved or side-effects develop (drug levels may
be helpful)
• Optimize compliance (use minimum number of doses per day)
• If first drug fails, start second first-line drug whilst gradually
withdrawing first
• If second drug fails, start second-line drug in combination with
preferred first-line drug at maximum tolerated dose (beware
interactions)
• If this combination fails (seizures continue or side-effects
develop), replace second-line drug with alternative second line
drug

17. Contd..
• If this combination fails
– check compliance and reconsider diagnosis (is
there an occult structural or metabolic lesion or
are seizures truly epileptic?)
– consider alternative, non-drug treatments (e.g.
epilepsy surgery, vagal nerve stimulation)
• Do not use more than two drugs in
combination at any one time

18. Status epilepticus
• It is defined as a seizure or a series of seizures
lasting >5 minutes without patient regaining
awareness between the attacks.
• Most commonly this refers to recurrent tonic
clonic seizures (major status) and is a life-
threatening medical emergency

19. Management of status epilepticus
Initial:
• Ensure airway is patent, give oxygen to prevent cerebral
hypoxia, and secure intravenous access
• Draw blood for glucose, urea and electrolytes (including
Ca and Mg), and liver function, and store a sample for
future analysis (e.g. drug misuse)
• Give diazepam 10 mg i.v. (or rectally) or lorazepam 4 mg
i.v.—repeat once only after 15 mins
• Transfer to intensive care area, monitoring neurological
condition, blood pressure, respiration and blood gases,
intubating and ventilating patient if appropriate

20. Ongoing:
If seizures continue after 30 mins
– I.v. infusion (with cardiac monitoring) with one of:
– Phenytoin: 15 mg/kg at 50 mg/min
– Fosphenytoin: 15 mg/kg at 100 mg/min
– Phenobarbital: 10 mg/kg at 100 mg/min
If seizures still continue after 30–60 mins
– Start treatment for refractory status with intubation, ventilation,
– and general anaesthesia using propofol or thiopental
Once status controlled
– Commence longer-term anticonvulsant medication with one of:
– Sodium valproate 10 mg/kg i.v. over 3–5 mins, then800–2000 mg/day
– Phenytoin: give loading dose (if not already usedas above) of 15
mg/kg, infuse at < 50 mg/min, then 300 mg/day
– Carbamazepine 400 mg by nasogastric tube, then400–1200 mg/day
– Investigate cause

21. References
• Davidson’s principles and practice of medicine
21st edition