1. EMERGENCY MANAGEMENT OF
SEIZURES
BY
DR. EKE EGHOSASERE PAUL
EPU
FMC, KEFFI

2. INTRODUCTION
• Seizure: A sudden, involuntary, time-
limited alteration in behavior, motor
activity, autonomic function,
consciousness, or sensation,
accompanied by an abnormal electrical
discharge in the brain
• Origin: Latin sacire – to take possession
of
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3. Epidemiology
• More than 200,000 new cases diagnosed each year
• Incidence highest under the age of 2 (and over 65)
• Males slightly more likely to develop siezures than
females
• Incidence greater in Blacks and socially
disadvantaged populations
• In 70% of new cases, no cause is apparent
• Generalized seizures more common < 10years,
afterwards more than half of all new cases are partial
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4. • Typical frank seizures are not present in
neonates
• It is important to identify subtle seizures like
abnormal eye movements, lip smacking,
abnormal tongue movements, repetitive
chewing, drooling, yawning, pedalling, apnea,
focal or multifocal clonic, tonic posturing of
limbs and myoclonic seizures
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5. Pathophysiology of Seizures
• Action potentials occur normally in nerve cells
(neuron) for impulse transmission
• AP occurs due to depolarization of neuronal
membrane propagating down the axon for
neurotransmitter release at the terminal
• Neurotransmitters: endogenous chemicals
that transmit signals from a neuron to target
cell across a synapse
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6. Pathophysiology Contd.
• Neurotransmitters are either excitatory
or inhibitory depending on the properties
of the receptors
• In the brain and spinal cord, glutamate is
the main excitatory NT
• Main inhibitory is Gamma- aminobutyric
acid (GABA)
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7. Pathophysiology Contd.
Seizure initiation: characterized by 2 concurrent events
– High frequency bursts of Action Potentials
Influx of extracellular Ca++ Opening of voltage
dependent Na+ channels Influx of Na+
Prolonged depolarization Generation of repetitive
APs
– Hypersynchronization of a neuronal population
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8. Pathophysiology Contd.
Sufficient burst activity  recruitment of
surrounding neurons  loss of surround
inhibition  spread of seizure activity into
contiguous areas via local cortical
connections  spread to more distant
areas via long association pathways e.g.
corpus callosum
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9. Causes of Seizures (Triggers)
Afebrile Seizures:
• Dehydration
• Oxygen deprivation eg. anaemia
• Stress—emotional or physical
• Metabolic conditions—hypoglycaemia,
hyperglycaemia, ↓Ca, ↑K, ↓Mg, ↓Na, ↑Na,
↑Urea, ↑Creatinine
• Medications e.g. pentazocine, aminophylline,
insulin
• Alcohol consumption—older children
Febrile causes: Infections eg. Malaria, Meningitis,
Tuberculosis, encephalitis
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10. • NEUROCUTANEOUS SYNDROMES – tuberous
sclerosis, neurofibromatosis, Sturge-Weber
syndrome, linear sebaceous naevus,
incontinentia pigmenti
• SYSTEMIC DISORDERS – vasculitis, SLE,
hypertensive encephalopathy, renal failure,
hepatic encephalopathy
• OTHERS – trauma, tumour, idiopathic, familial
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11. Classification
INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE)
• Partial seizures: Now Focal Seizures
– Simple partial (consciousness retained)
•Motor
•Sensory
•Autonomic
•Psychic
– Complex partial (consciousness impaired)
•Simple partial, followed by impaired consciousness
•Consciousness impaired at onset
– Partial seizures with secondary generalization
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12. Classification Contd.
• Generalized seizures
- Tonic–clonic (in any combination)
- Absence
Typical
Atypical
- Absence with special features
Myoclonic absence
Eyelid myoclonia
- Myoclonic
Myoclonic
Myoclonic atonic
Myoclonic tonic
- Clonic
- Tonic
- Atonic
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13. Management
• Stabilization: A, B, C
• An IV line should be established, if possible
blood samples collected for sugar, calcium,
magnesium, electrolytes, blood cell count and
CRP
• If situation permits, rapid screening of blood
sugar should be done
• A quick history taken while resuscitative
measures are being instituted may reveal the
cause of the seizure
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14. • Lorazepam 0.1mg/kg is drug of choice, has
smaller volume of distribution and longer half-life
than diazepam, which can also be given at 0.1-
0.3mg/kg
• IM Paraldehyde 0.1mg/kg or 1ml/year of life up
to 5yrs, not more than 5ml
• Phenobarbitone 15-20mg/kg slow IV as loading
dose, if seizure not controlled after 15mins, a 2nd
loading dose 10-20mg/kg can be given. Maximum
total loading dose=50-60mg. Maintenance dose is
5mg/kg in two divided doses
• Phenytoin 15-25mg/kg loading dose diluted in
normal saline is given slowly IV over 15mins,
maintenance dose is 5mg/kg in 2 divided doses
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15. INVESTIGATIONS
• BEDSIDE TESTS – RBG, urinalysis
• SERUM ELECTROLYTES
– Na+, Cl-, Ca2+, Mg2+
– Urea, Creatinine
• CSF analysis
• ELECTROENCEPHALOGRAPHY (EEG)
• NEURO-IMAGING
– Skull X-Ray
– Computed Tomography (CT) scan
– Magnetic Resonance (MRI) scan
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16. STATUS EPILEPTICUS
• Definition – seizure lasting ≥ 30mins/repeated
episode without regain of consciousness.
• Types – Convulsive; Non-convulsive
• Convulsive (GCSE)
– Life threatening emergency
– Potential for complication – irreversible CNS
damage (neuronal loss due to anoxia),
cardiac arrhythmias, pulmonary oedema,
renal failure.
• Factors –hypoglycemia, ↓Na+,↓Ca2+
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17. • If seizure persists:
– additional phenytion (5 -10mg/kg) or
– phenobarbitone 50 – 100mg/min, up to
20mg/kg
• If still unresponsive:
– Barbiturate Anaesthesia:
- Pentobarbitone: loading dose = 5 – 15mg/kg
then 0.5 to 5mg/kg/hr with EEG monitoring
• Sometimes before anaesthesia – Midazolam
(Benzodiazepine) or Propofol infusions
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18. After Aborting Seizure
• Hypoglycaemia (< or equal to 40mg/dl): IV 10%
dextrose 2-4ml/kg over 3min, then intravenous
dextrose containing infusion is started
• Hypocalcaemia (< or equal to 7mg/dl): calcium
gluconate 10% soulition, 2ml/kg is given IV slowly
over 5-10mins under cardiac monitor
• Hyponatraemia (< or equal to 125mg/dl):
corrected with 3% saline
(125-Serum Na) X weight X 0.6 mEq of Na+
1ml = 0.5mEq, slowly over 4hours
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19. • Dehydration: Correct
• Anaemia: Transfuse
• Dialysis may be required in some cases
• Infection eg. Malaria, Menigitis: Treat
appropriately
• Once cause is determined, caregivers should
be appropriately counselled on the cause of
the condition with the aim of preventing
reoccurence
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20. Wa Rué Se O!!!
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