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Epilepsy

Description

An in-depth report on the types, causes, diagnosis, and treatment of epilepsy.

Treatment

Immediate Seizure Treatment

You cannot stop a seizure, but you can help the patient prevent serious injury.

First, it is extremely important to remain calm and not panic. Then 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. Patients should be taken to an emergency room if:

• Any seizure lasts beyond 2 - 3 minutes
• The patient has been injured
• The patient is pregnant
• The patient is diabetic
• Parents, caregivers, or bystanders are at all uncertain

Children with seizures caused by fever rarely require any treatment other than taking precautions to prevent obstruction and reduce the fever. Research on adult patients has found that only 5.7% of adults with epilepsy who refused to go to the hospital following a seizure had a subsequent seizure during the study's 3-day follow-up period. Hospitalization 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 doctor after a seizure occurs.

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 anti-anxiety 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, although 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:

• 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 2 hours. Initial management of status epilepticus consists of:

• 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 (IV) 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. Midazolam is the only benzodiazepine available as a muscular injection. Intravenous diazepam 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 doctors 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 works faster, and is safer than phenytoin.
• Phenobarbital. Although effective, barbiturates, such as phenobarbital (Barbita, Luminal), can reduce consciousness, blood pressure, and respiratory rate. They are generally used only when other drugs have failed.

Other medications or higher doses of the above-mentioned drugs may be used for status epilepticus patients who fail to 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. A 2003 analysis of 22 studies suggested that this drug poses an increased risk of mortality. Experts recommended that this drug 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.

• Review Date: 11/15/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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