Epilepsy

Description

Immediate Treatment

When a person experiences a seizure, caretakers or bystanders cannot stop it, but they can prevent serious injury.

First, it is extremely important for caregivers to remain calm and not panic. They should take the following actions:

• Wipe away any excess saliva to prevent obstruction of the airway. Do not put anything in the patient's mouth. It is an old wives' tale that people having seizures will swallow their tongues.
• Turn the victim gently on the side. Do not try to hold the patient down to prevent shaking.
• Rest the patient's head on something flat and soft to protect it from banging on the floor and to support the neck.
• Move sharp objects out of the way to prevent injury.

Do not leave the seizure victim alone. Anyone nearby should call 911 and the patient should be taken to an emergency room under the following circumstances:

• If any seizure lasts beyond two or three minutes.
• If the patient has been injured.
• If the patient is pregnant.
• If the patient is diabetic.
• If parents or bystanders are at all uncertain.

Children with seizures caused by fever rarely require any treatment other than taking precautions that will prevent obstruction and reduce the fever. And a 2001 study revealed that among adult patients with known epilepsy who refused to go to the hospital following a seizure, only 5.8% had a subsequent seizure during the study's three-day follow-up period. Hospitalization then may not be necessary in many patients whose seizure is not severe or repetitive and who have no risk factors for complications. All patients or caregivers, however, should contact their physician in the event of a seizure.

Drugs Used for Managing Acute Repetitive Seizures

The initial treatment for acute repetitive seizures, two or more seizures that occur over minutes to hours separated by periods of consciousness, are antianxiety drugs known as benzodiazepines. They include diazepam (Valium, Diastat) or lorazepam (Ativan). These drugs are available in the following forms:

• Tablets taken orally or under the tongue (sublingual). Oral tablets are difficult to give a patient who is convulsing, however.
• Rectal solutions, gels, or suppositories. Rectal administration is preferred. Solutions and gels work faster than suppositories. Diastat is rectal gel form of diazepam, and though more expensive than rectal solutions, it can be administered at home by a trained caregiver. The gel is safe and effective in reducing seizure frequency in both children and adults, and it may help prevent status epilepticus. Studies suggest that it significantly reduces the rate of hospitalization, and may even prove to be an alternative to drug therapy among children with prolonged or repetitive seizures.

Treatment of Status Epilepticus

The treatment goals of status epilepticus are the following:

• Stop the seizures.
• Prevent recurrence.
• Determine and prevent any factors that might have triggered it.
• Manage any complications.

Initial Management. The earlier a patient is treated, the better the results. In one study, seizures stopped in 80% of patients who were treated within 30 minutes. Only 40% of patients responded when they were treated after two hours. Initial management of status epilepticus consists of the following:

• Administer any seizure medications.
• Support systems to maintain or attain normal breathing, blood pressure, electrolyte balances, body temperature, and heart functions.
• Oxygen for patients who may need it.
• Attention by medical personnel trained to determine any treatable cause of status epilepticus, such as drug withdrawal, low blood sugar, infection, substance abuse (particularly cocaine), or eclampsia (elevated blood pressure induced by pregnancy).

Medications for Status Epilepticus. One or more of the following medications may be used initially:

• Benzodiazepine. An intravenously administered or injected benzodiazepine such as lorazepam (Ativan), diazepam (Valium), clonazepam, or midazolam (Versed) is usually used. Lorazepam or clonazepam is now preferred since they have a longer duration of action. Of note, midazolam is the only benzodiazepine available as a muscular injection and may prove to be effective for children, as safe as other benzodiazepines and safer than barbiturates. Intravenous diazepam, a drug known as a benzodiazepines, is currently the first choice for children with status epilepticus. Rectal administration of benzodiazepines, either diazepam or lorazepam, may also be beneficial. Some evidence suggests that rectal administration of lorazepam is safer and more effective than diazepam in children, but more research is needed.
• Phenytoin or Fosphenytoin. Many physicians use phenytoin or fosphenytoin if seizures are not controlled by a benzodiazepine. These drugs must be prescribed with caution for patients who have liver and blood abnormalities or certain heart arrhythmias. Fosphenytoin is similar but has a faster action and is safer than phenytoin.
• Phenobarbital. Although effective, barbiturates, such as phenobarbital (Barbita, Luminal), can reduce consciousness, blood pressure, and respiratory rate and are generally used only when other drugs have failed.

Other medications or higher doses may be used for status epilepticus that does not respond to initial treatments. They include:

• Higher-dose barbiturates.
• Higher-dose intravenous benzodiazepines. In one study midazolam, the injected benzodiazepine, was as effective and possibly safer than propofol, an intravenous sedative also used for uncontrolled status epilepticus.
• Propofol (Diprivan), an intravenously administered sedative. Of note, a 2003 analysis of 22 studies suggested that this drug poses an increased risk of mortality. Experts recommended that this agent not be used routinely until better trials have been performed.

All of the medications mentioned carry a risk for hypotension, an abrupt and possibly dangerous drop in blood pressure, which may require treatment.