What are the key steps in emergency seizure treatment. How can first aid be administered during a seizure emergency. What is the definition of status epilepticus. How do prolonged seizures affect the body. What is the clinical perspective on acute seizures in children. How should emergency supportive treatment be provided for seizures.

Understanding Status Epilepticus: Definitions and Implications

Status epilepticus is a severe medical condition that requires immediate attention. But what exactly does this term mean? Status epilepticus is typically defined as two or more seizures occurring consecutively without full recovery of consciousness in between, or as recurrent epileptic seizures lasting for more than 30 minutes. However, this strict definition doesn’t always reflect the urgency experienced by clinicians when dealing with a convulsing child.

From a pragmatic perspective, status epilepticus can be viewed as the severe end of a continuum during the progressive evolution of an unrelenting seizure. This approach recognizes the potential life-threatening complications that can arise in central, metabolic, and systemic physiology during prolonged seizures.

Physiological Changes During Prolonged Seizures

• Central nervous system alterations
• Metabolic derangements
• Systemic physiological changes

These changes can have significant implications for patient health and treatment strategies. Understanding these physiological alterations is crucial for healthcare providers to effectively manage seizure emergencies.

Clinical Perspective on Acute Seizures in Children

When considering emergency seizure treatment, it’s essential to understand the clinical context and natural history of acute seizures and status epilepticus in children. How common are these events, and what factors influence their occurrence?

In many parts of the world, status epilepticus in childhood is often associated with fever, with 25-50% of cases presenting this symptom. However, the frequency of status epilepticus can vary significantly depending on the region and definition used.

In the UK, for instance, status epilepticus (defined as a 30-minute episode) is relatively infrequent. A long-term cohort study found that only 37 out of 14,676 children had experienced an episode of status epilepticus by their 10th birthday. Similarly, a one-year study in a district general hospital reported only 12 episodes of status epilepticus lasting longer than 30 minutes out of 254 seizure episodes in children presenting to the emergency department.

Key Statistics on Childhood Seizures

• 25-50% of status epilepticus cases in children are associated with fever
• Only 0.25% of children in a UK cohort study experienced status epilepticus by age 10
• Approximately 4.7% of seizure episodes in a UK emergency department lasted longer than 30 minutes

Emergency Supportive Treatment: First Steps in Seizure Management

When a child arrives at the emergency department still convulsing, immediate supportive treatment is crucial. What are the first steps in managing a seizure emergency?

Airway Management and Oxygenation

The first priority in seizure management is ensuring proper airway function and oxygenation. Hypoxaemia can both cause and result from a seizure, and in severe cases, bradycardia and hypotension may complicate the episode. Here’s a step-by-step approach to managing the airway:

1. Position the head and neck to keep the airway open
2. Suction the airway if necessary to ensure patency
3. Insert an oral airway if feasible and safe
4. Administer oxygen via nasal cannula or mask
5. Use bag-valve-mask ventilation if needed
6. Consider endotracheal intubation if respiratory assistance is required for an extended period

It’s important to note that while airway management is crucial, administering an anticonvulsant remains a top priority in seizure emergencies.

Anticonvulsant Treatment: Balancing Urgency and Safety

The administration of anticonvulsants is a critical aspect of emergency seizure treatment. However, the approach to anticonvulsant therapy must balance the urgency of stopping the seizure with the potential risks of treatment.

Given that most acute seizures in children stop spontaneously, often during transit to the hospital, healthcare providers should assume that if a child is still convulsing upon arrival at the emergency department, the seizure will likely continue unless treated. This raises an important question: How rapidly should such treatment be carried out?

Considerations in Anticonvulsant Administration

• Potential for spontaneous seizure resolution
• Risk of respiratory depression and hypotension from overtreatment
• Need for standardized, safe administration protocols

One expert in the field has posed a thought-provoking question: “Does the morbidity of the treatment of seizures in the emergency room to prevent status now exceed the morbidity of the status epilepticus itself?” While definitive clinical data to answer this question fully is lacking, it underscores the importance of ensuring that anticonvulsant treatment is administered safely and in a standardized manner understood by all emergency personnel involved.

Benzodiazepines in Pediatric Seizure Management

Benzodiazepines play a crucial role in the emergency treatment of acute seizures and status epilepticus in children. But what makes these medications particularly suitable for pediatric seizure management?

Benzodiazepines are widely used due to their rapid onset of action, effectiveness in stopping seizures, and relatively good safety profile when administered correctly. The most commonly used benzodiazepines in pediatric seizure emergencies include:

• Diazepam
• Lorazepam
• Midazolam

Each of these medications has its own advantages and considerations in terms of route of administration, onset of action, and duration of effect. The choice of benzodiazepine often depends on factors such as the child’s age, seizure type, and local treatment protocols.

Comparing Benzodiazepines for Seizure Management

It’s important to note that while benzodiazepines are effective in stopping seizures, they can also cause respiratory depression, particularly when administered rapidly or in high doses. Therefore, careful monitoring and preparation for potential respiratory support are essential when using these medications.

Developing Standardized Protocols for Seizure Management

Given the complexity and urgency of seizure emergencies, developing and implementing standardized protocols for seizure management is crucial. How can healthcare facilities ensure consistent and effective treatment of seizures?

Standardized protocols help reduce variability in care, minimize errors, and improve patient outcomes. Key elements of an effective seizure management protocol include:

1. Clear definitions of seizure types and status epilepticus
2. Step-by-step guidelines for initial assessment and supportive care
3. Specific medication dosages and administration routes based on patient age and weight
4. Timelines for escalation of treatment if initial interventions are ineffective
5. Guidance on when to consider additional diagnostic tests or consultations
6. Protocols for monitoring and managing potential complications

These protocols should be developed collaboratively by emergency medicine, neurology, and pediatric specialists, and should be regularly updated based on the latest evidence and guidelines.

Benefits of Standardized Seizure Management Protocols

• Improved consistency of care across different healthcare providers
• Reduced time to initiation of appropriate treatment
• Decreased risk of medication errors
• Enhanced communication among healthcare team members
• Facilitated quality improvement efforts through standardized metrics

Long-term Considerations in Pediatric Seizure Management

While emergency treatment is crucial, managing seizures in children also requires consideration of long-term implications and follow-up care. What factors should be addressed in the ongoing management of pediatric seizure disorders?

Long-term management of seizures in children involves a multifaceted approach that goes beyond acute treatment. Key considerations include:

Diagnostic Evaluation

After the acute seizure has been managed, a comprehensive diagnostic evaluation is often necessary to determine the underlying cause of the seizure and guide further treatment. This may include:

• Neuroimaging studies (MRI, CT scan)
• Electroencephalogram (EEG)
• Blood tests to check for metabolic abnormalities or infections
• Genetic testing in some cases

Chronic Antiepileptic Therapy

For children with recurrent seizures or diagnosed epilepsy, long-term antiepileptic medication may be necessary. The choice of medication depends on factors such as seizure type, age of the child, potential side effects, and comorbid conditions.

Psychosocial Support

Living with a seizure disorder can have significant psychological and social impacts on children and their families. Providing appropriate support and resources is crucial for optimal management. This may include:

• Educational support and accommodations
• Psychological counseling
• Family support groups
• Guidance on lifestyle modifications and safety precautions

Regular Follow-up and Monitoring

Ongoing medical follow-up is essential to monitor seizure control, medication effectiveness and side effects, and overall developmental progress. This typically involves regular visits with a pediatric neurologist or epileptologist.

By addressing these long-term considerations, healthcare providers can help ensure comprehensive care for children with seizure disorders, potentially improving their quality of life and long-term outcomes.

Emergency treatment of acute seizures and status epilepticus

This article discusses some of the issues related to protocols for emergency anticonvulsant treatment of acute seizures and status epilepticus with particular emphasis on the use of benzodiazepines in children presenting to accident and emergency departments.

Definitions

Infants and children can have both convulsive and non-convulsive forms of prolonged seizures. This article addresses only convulsive episodes of status epilepticus, which is strictly defined as two or more seizures occurring consecutively without an intervening period of full recovery of consciousness, or as recurrent epileptic seizures lasting for more than 30 minutes.1 Unfortunately, such a precise definition of status epilepticus, although useful for epidemiological analysis and evaluation of therapeutic interventions, conceals a sometimes frenetic approach to acute care and the urgency experienced by clinicians when confronted with a convulsing child, irrespective of how long the episode has lasted. It therefore seems more appropriate to take a pragmatic view and consider status epilepticus as the severe end of a continuum encountered during the progressive evolution of an unrelenting seizure, which heralds a potentially life threatening sequence of complications in central, metabolic, and systemic physiology (table 1).2-5 This somewhat looser approach is reflected in the paediatric literature where seizure episodes of considerably less than 30 minutes have been considered as status epilepticus.6
7

Table 1

Systemic physiology, metabolic, as well as central changes, and derangements during prolonged seizures^2–5

Clinical perspective

Both the clinical context and natural history of acute seizures and status epilepticus are very important considerations when evaluating choice of anticonvulsant treatment. In many parts of the world status epilepticus in childhood is often associated with fever, although there is wide variation in the proportion of patients who have this symptom (25–50%). 8-10

In the UK, status epilepticus (defined as a 30 minute episode) is an infrequent occurrence. For example, Verity et al reported in 19939 that only 37 of 14 676 children from a long term cohort study had an episode of status epilepticus by their 10th birthday. Similarly, Smithet al reported in 199610 only 12 episodes of status epilepticus (lasting longer than 30 minutes) in 254 seizure episodes occurring in children presenting to an accident and emergency department over one year; this was from a surrounding population of 70 000 children.

Clinical strategy

Smith et al’s district general hospital study10 also illustrated another important feature of acute seizures in children: 80% of them did not require any anticonvulsant treatment in the emergency department. Therefore, given that most acute seizures in children stop spontaneously, usually during transit to hospital, we should assume that if a child is still convulsing on arrival in the emergency department the seizure will continue unless treated. How rapidly such treatment should be carried out then becomes an important issue. Status epilepticus in the 1990s has a relatively low morbidity and mortality directly attributable to the seizure itself,8
9 and an overexuberant approach with anticonvulsants may expose patients to the unnecessary iatrogenic risks of respiratory depression and hypotension. One commentator has raised the important question “Does the morbidity of the treatment of seizures in the emergency room to prevent status now exceed the morbidity of the status epilepticus itself?”.11 In the absence of any clear clinical data to answer this question fully, the onus on those involved with acute seizure treatment is to ensure that it is administered safely and in a standardised fashion that is understood by all emergency personnel involved.

Emergency supportive treatment

Anyone who is still convulsing on arrival in the emergency department should receive immediate, basic, supportive treatment.

AIRWAY AND OXYGENATION

Hypoxaemia can be both the cause and the consequence of a seizure. In severe episodes bradycardia and hypotension may complicate the seizure. To begin with, the head and neck should be positioned to keep the airway open and, if necessary, the airway should be suctioned to ensure patency. If feasible, an oral airway can be inserted—although this should only be done if there is no likelihood of trauma to the mouth and teeth—and oxygen should be administered by nasal cannula or mask and bag-valve-mask ventilation. If the need for respiratory assistance persists after the patient has been supported by bag-valve-mask, endotracheal intubation should be considered. However, administering an anticonvulsant is a top priority because managing the airway and assisting respiration are much easier after the convulsion has stopped. If persistent convulsive activity causes hypoventilation necessitating endotracheal intubation, seizure activity can be stopped temporarily with a high dose of a short acting barbiturate or midazolam, and patient ventilation dysynchrony can be abolished with a neuromuscular blocking agent.

GLUCOSE

Hypoglycaemia is a rare cause of prolonged seizures in children. However, all patients should have prompt measurement of blood glucose. If hypoglycaemia (blood glucose < 3 mmol/l) is documented or if it is impossible to obtain the measurement, intravenous glucose (5 ml/kg) should be administered as 10% glucose.

BLOOD PRESSURE

Hypotension can potentiate or exacerbate any derangement in cerebral physiology and function. Systolic blood pressure should be maintained at normal levels. If there is no evidence of shock, minimal isotonic fluids of 2–3 ml/kg/h should be given initially.

Anticonvulsant treatment

In the convulsing patient, initial supportive, therapeutic, and diagnostic measures need to be conducted simultaneously. The goal of anticonvulsant treatment is the rapid termination of clinical and electrical seizure activity by the prompt administration of appropriate drugs in adequate doses, with attention to the possibility of complicating apnoea, hypoventilation, and other metabolic abnormalities.

PROLONGED SEIZURES AND ANTICONVULSANT RESPONSIVENESS

The concept of acute seizures and status epilepticus being on a continuum is useful in regards to administering anticonvulsant treatment. For example, using diazepam in controlled experimental studies of prolonged seizures has established that the longer the duration of a seizure episode before treatment (ranging from 7–130 minutes) the more difficult it is to stop, and the more likely it is that diazepam will convert an overt motor episode into another subtle or electroencephalographic form of seizure activity.12 As similar findings have been reported in man,13 the need for rapid, definitive treatment of acute seizures, irrespective of whether 30 minutes has elapsed, is underscored.

ANTICONVULSANT PROTOCOL

There is a dearth of evidence in children that one particular anticonvulsant protocol is best for treating acute seizures. There is need for a formal systematic review of the literature to identify what would be the appropriate strategy for future investigation. A clear path or treatment plan however is necessary now, and indeed has been recommended for effective and consistent management.14 One such approach is that used by the “Advanced Life Support Group” in their recommendations for advanced paediatric life support (fig1).15 While endorsing wholly this specific approach, not least because it is taught widely and has been adopted as a national standard of care, the main problem with this approach is the time it might take to stop a seizure if official recommendations are adhered to. For example, 25 to 30 minutes of seizure activity may have elapsed before either phenytoin or phenobarbitone is given: five minutes before the first dose of diazepam, then five minutes to see if diazepam is effective, then the second dose of diazepam, then five minutes to see if this dose is effective, then a dose of paraldehyde, then 15 to 20 minutes to see if this is effective, etc. We shall therefore consider other emerging strategies using only benzodiazepine agents (figs 1 and2),16 which may simplify our approach to acute emergency seizure treatment.

Figure 1

Timing for the Advanced Paediatric Life Support (APLS) “standard” anticonvulsant protocol for status epilepticus¹⁵ alongside a potentially challenging approach using only “benzodiazepines”. The time line highlights a problem with the APLS approach: it may be 25 minutes before progressing to phenytoin or phenobarbitone. *Do not use if the child is known to be on regular phenytoin.

Figure 2

Chemical structure and pharmacokinetic properties of diazepam, lorazepam, and midazolam illustrating some of the similarities between these benzodiazepine GABA_A agonists. Adult pharmacokinetics¹⁶: V_d, volume of distribution; T_½α, distribution half life; T_½β, elimination half life; Cl, clearance. All three drugs are metabolised in the liver and excreted via the kidney. All three have significant protein binding (> 88%).

Benzodiazepine agents

PREHOSPITAL TREATMENT

The efficacy of intravenous diazepam for the treatment of status epilepticus is well recognised with termination of episodes in some 80% of cases. 17 However, safety is a significant concern as apnoea and respiratory depression are common complications.18 Therefore, except in known cases of recurrent prolonged seizures, drug treatment in the UK has traditionally been reserved for administration after arriving in hospital. If, as already discussed, diazepam is not only effective treatment but also better when administered earlier, why not give it before arriving at hospital—providing it can be carried out safely? In support of this argument is a recent American retrospective, case-control, study by Alldredge et al.7 Using a definition of status epilepticus as seizures lasting longer than 15 minutes, these authors found (in 45 convulsive episodes) that prehospital treatment with intravenous diazepam (0.2 mg/kg) or rectal diazepam (0.6 mg/kg) by paramedical staff significantly shortened the duration of status epilepticus (mean for prehospital 32 minutes v mean for emergency department 60 minutes; p = 0.007) and reduced the likelihood of recurrent seizures in the emergency department (58%v 85%; p = 0. 045). This study found no difference between the effectiveness of rectal and intravenous diazepam. This experience seems to confirm the experimental data already described,13 but is such an approach safe?

The possible complication of respiratory depression from rectal diazepam has been considered in some depth in the treatment of repeated febrile convulsions.19 Respiratory depression from rectal diazepam (0.2–0.5 mg/kg) is rare among children studied to date, probably because of the slower rise in serum diazepam concentrations compared with that achieved after intravenous administration. The clinical effect from rectal diazepam occurs in approximately five minutes and peak serum concentrations are achieved 6–10 minutes after administration.20
21 Knudsen22 reported no respiratory complications in 376 children treated with rectal diazepam. (The upper limit of the 95% confidence interval for 0/376 is 8 per 1000 cases.) A literature review of 13 papers on rectal diazepam by Siegler in 199023 identified only three cases of reversible respiratory depression in 843 cases. Some patients, however, may be at more risk of respiratory depression—for example, those with serious comorbidity and those on regular anticonvulsants or with chronic central nervous system abnormalities.23 In these patients a lower rectal dose of 0.25 mg/kg is advised.

Therefore, the literature supports the use of a single prehospital dose of rectal diazepam, although attendants should be aware of the possibility of respiratory depression and be able to support breathing if necessary.

FIRST LINE HOSPITAL TREATMENT

A child who is still convulsing on arrival in hospital can be assumed to have had a seizure lasting at least 10 minutes and therefore will require emergency treatment. Some children may have already received rectal diazepam. In this phase of management the issues are whether diazepam is the treatment of choice and, if it is, should it be used more than once. Although the precise serum diazepam concentration required for a therapeutic effect is not known, concentrations of 150–336 ng/ml are associated with arrest of seizure activity. 24 These are achieved with a single dose of rectal diazepam,20
22 which questions the notion that further doses would be of benefit in those whose seizure has not come under control—unless of course administration of the first dose has been unreliable or if a second episode has occurred. Few studies in children have looked specifically at the effectiveness of serial doses of diazepam when the first dose has failed to control the seizure. However, some information on this question can be learnt indirectly from a recent prospective study reported by Appletonet al.25 Of 53 patients presenting with acute seizures to an emergency department, 28 responded to a single dose of rectal or intravenous diazepam (0.3–0.4 mg/kg). In the 25 who required a second dose, 17 also needed additional anticonvulsant drugs. This may have been because of the local protocol, but it does suggest that in those who do not respond to an initial dose of diazepam, the second dose is also likely to be ineffective. Therefore, if giving diazepam twice is questionable, is there a better alternative?

Choices from phenobarbitone, phenytoin, and lorazepam as candidate alternative drugs for status epilepticus have been debated in the literature.16
26
27 Lorazepam, a hydroxylated benzodiazepine (fig 2), is an effective anticonvulsant with a response latency comparable to that of diazepam, and it has the advantage of a longer duration of anticonvulsant effect than diazepam.27Although there are few studies comparing lorazepam with established standards, it has been recommended as one of the first line agents for status epilepticus for the above reasons.27 One preliminary study25 compared lorazepam with diazepam for the treatment of acute convulsions and status epilepticus in 102 children in a prospective, open (odd and even dates) trial. Sixteen children had to be excluded and of the remaining 86, convulsions were controlled in 76% of patients treated with a single dose of lorazepam (0.05–0.1 mg/kg) and 51% of patients treated with a single dose of diazepam. Significantly fewer patients treated with lorazepam required additional anticonvulsants to terminate the seizure. Respiratory depression occurred in 3% of lorazepam treated patients and 15% of diazepam treated patients. No patient who received lorazepam required admission to the intensive care unit for either respiratory depression or refractory status epilepticus, whereas all eight of the patients with diazepam related respiratory depression were admitted for intensive care. Importantly, rectal and parenteral lorazepam were equally efficacious.

Despite these favourable aspects of lorazepam, there are still indications for the other agents. Lorazepam appears to be less effective in patients chronically treated with other benzodiazepine anticonvulsants and in those who will need the drug more than once.27 In both of these instances phenobarbitone appears to be superior,26
28 although there is little comparative clinical data for these agents and phenytoin. In practice, choice between anticonvulsants appears to relate to age and aetiology. In infants, the metabolism of phenobarbitone is more predictable than the metabolism of phenytoin. Phenytoin has a role when there is concern about impaired cerebral function and the need for clinical assessment of neurology.

REFRACTORY SEIZURES

Refractory status epilepticus has been defined as a seizure that is unresponsive to an adequate dose of a first line parenteral anticonvulsant28; or a seizure that is unresponsive to at least two doses of diazepam intravenously or rectally in succession followed by phenytoin/phenobarbitone or both (20 mg/kg) given over 30 minutes as an infusion, or failure to respond to the latter alone or in combination15
28-30; or a seizure that continues for 60 to 90 minutes after the initiation of treatment.1 This lack of consistency in definition is important when one considers the treatment and its consequences. Traditionally, for the most severe cases of status epilepticus induction of general anaesthesia has been recommended using a short acting barbiturate such as thiopentone (4–8 mg/kg bolus followed by infusion of up to 10 mg/kg/h) along with supportive endotracheal intubation and mechanical ventilation. 15
29 An alternative, effective approach has been to use, if necessary, repeated bolus doses of intravenous phenobarbitone (10 mg/kg) every 30 minutes, without reference to a predetermined maximum level or dose, after one dose of intravenous diazepam has failed to control a seizure.28 A number of questions arise—for example, at what point is induction of anaesthesia overexuberant? Is it really necessary to wait 60 to 90 minutes before deciding that standard anticonvulsants are ineffective? When is it inevitable that standard anticonvulsants are unlikely to work—after the second dose of diazepam, after the second drug, or after the third drug? Some of these issues have been addressed already. The main disadvantage of thiopentone relates to its high lipid solubility and slow metabolism, which results in a prolonged period of intensive care support before a child is completely awake and cooperative once treatment has been stopped.29 Similarly, prolonged intensive care will be necessary when using the very high dose phenobarbitone strategy. 28

A newer approach, recently delineated in children, has been to use midazolam,30
31 an imidazobenzodiazepine (fig 2). This drug has a relatively short elimination half life of 1.5 to 3.5 hours, and preclinical and clinical analyses indicate that it shares anxiolytic, muscle relaxant, hypnotic, and anticonvulsant actions with other benzodiazepines. Rivera et al reported the use of midazolam in 24 children (aged 2 months to 2 years) with status epilepticus failing to respond to three repeated doses of 0.3 mg/kg diazepam, 20 mg/kg of phenobarbitone, and 20 mg/kg phenytoin.30 Intravenous midazolam given as a bolus of 0.15 mg/kg followed by continuous infusion of 1 μg/kg/min (with increasing increments of 1 μg/kg/min every 15 minutes until seizure control) was successful in all cases. The average time to achieve seizure control was 47 minutes (range 15 minutes to 4.5 hours) with a mean infusion dose of 2.3 μg/kg/min (range 1 to 18). After stopping the infusion, the average time to full consciousness was just over four hours (range 2 to 8. 5). Lal Koul et alrecently reported similar findings in a further 20 children.31

Given the structural and pharmacokinetic similarities between diazepam and midazolam (fig 2) and their similar mechanism of action via binding to the γ-aminobutyric acid A (GABA_A) receptor, it is pertinent to question “Why should midazolam be effective when other GABA_A agonists including phenobarbitone and benzodiazepines have failed?” As yet this cannot be answered from the available data, but it may relate to actions and interactions distant to the benzodiazepine binding site on the GABA_Areceptor.32 This therapeutic conundrum does however raise another important consideration—if midazolam is effective when all drugs have failed, would it be a better option earlier in acute seizure care? Lal Koul et al addressed this question in their report31 by using a midazolam infusion as their only treatment in eight patients who had seizure activity for at least 30 minutes. Once this treatment was started, control of the seizure was achieved within 10 to 60 minutes (mean 34). None of their patients required mechanical ventilation or endotracheal intubation.

What about the potential use of midazolam as a first line anticonvulsant for all acute seizures? In the accident and emergency department in predominantly adult series, intravenous33and intramuscular34 midazolam as first line treatment for seizures have been used effectively and safely. Galvin and Jelinek33 reported that intravenous midazolam alone was successful in stopping seizures in all 75 patients they treated. Intramuscular midazolam is also rapidly effective: in 36 of 38 patients undergoing seizures, seven of whom were children, seizures were controlled with a mean of 1 minute and 53 seconds.34 The two patients whose seizures continued despite intramuscular midazolam responded to another benzodiazepine given intravenously.

Conclusion

Devising a protocol for the management of status epilepticus with the optimal selection of anticonvulsant drugs is fraught with problems given the reality of clinical duty rotations and varied expertise of frontline staff. Introducing relatively new agents such as midazolam and lorazepam into an established pattern of practice will need to be justified. Inevitably, factors other than pharmacology and therapeutics will influence the specific approach adopted. What is right for a practice seeing head injury as the major cause of status epilepticus may not be appropriate for those dealing with central nervous system infection as the leading cause. The clinical context, cost, and logistics of delivering effective treatment and care are also important. Finally, diagnostic studies and the type and timing of investigation are a concern. Some of these aspects are well summarised elsewhere.35
36 However, irrespective of regional variance in practice, it is clear that much thought should be given to these issues at a local level. In a recent UK intensive care questionnaire study reported by Walker et al,
14 only 12% of the respondents were aware of a local protocol for status epilepticus.

Future direction

Perhaps not surprisingly there is a paucity of clinical data comparing drug regimens for status epilepticus, which means that there is still much to learn about this emergency. As alluded to already, there is a need to formalise and confirm our current ignorance in a systematic review. Building on this knowledge will inevitably require a number of specific studies concentrating on prehospital, first line, and refractory phases of drug treatment. For example: Is prehospital administration of rectal lorazepam by paramedical staff of benefit? Can midazolam be used as monotherapy, intranasal or rectal in the prehospital setting and then parenterally thereafter? Can we predict better those patients who will eventually prove to be refractory to treatment? For the present, standards such as that recommended by the Advanced Paediatric Life Support Group15 have been rightly adopted on a national level, but that should not detract from a constructive, investigational questioning of alternative or even better, more timely approaches, which have as their goal improved emergency care.

Emergency medication | Epilepsy Society

Most people’s seizures last the same length of time each time they happen and usually stop by themselves. However, sometimes seizures do not stop or one seizure follows another without the person recovering in between. When a seizure goes on for 5 minutes or more it is called status epilepticus (or ‘status’ for short).

Status during a tonic clonic (convulsive) seizure is a medical emergency and needs urgent treatment with emergency medication.

Treatment

The two emergency medications used to prevent status in the community (outside of the hospital setting) are midazolam and diazepam:

• Buccal (oromucosal) midazolam – is given into the buccal cavity (the side of the mouth between the cheek and the gum).
• Rectal diazepam – is given rectally (into the bottom).

Both these drugs are sedatives. Sedative drugs have a calming effect on the brain and can stop a seizure. Although it is rare, these emergency drugs can cause breathing difficulties so the person must be closely watched until they have fully recovered.

For people who have gone into status before, their doctor may prescribe midazolam or diazepam so that a carer can give it to them. Specialist training is needed to give emergency medication. It is also important that every individual who is prescribed diazepam or midazolam has a written plan (or protocol) about when they are given the medication.

A protocol includes specific information relating to a person’s medical condition. It is usually completed with or on behalf of someone with epilepsy and can include details about their medication, for example the dose, when to give it, and when to call for emergency help. You can download a sample protocol here. (Protocol by kind permission of Veriton Pharma Ltd)

Information booklets

We have produced two information booklets on emergency medication. These were updated in December 2020. Each booklet costs £1.20 (including p&p) and you can order them through the online shop.

As well as information about status epilepticus (‘status’) and how it is treated, the booklets cover issues such as protocols for emergency medication, training in giving emergency medication, correct dosage and a step by step illustrative guide on how to give buccal midazolam and rectal diazepam.

The booklets are designed to inform and support carers who give emergency medication to their family member. They are also designed for staff in residential care homes, nursing staff and anyone who is responsible for giving emergency medication within their workplace. They are ideal to be used alongside training in giving emergency medication and within the context of a written protocol or care plan for the individual with epilepsy.

Training

Epilepsy Society can provide training in giving emergency medication.

Information produced in December 2020

Medications Used for Seizure Emergencies

Rescue seizure medications are prescription medications used to stop a seizure while it is occurring. Emergency treatment of seizures may be necessary in a number of situations, including status epilepticus, cluster seizures, and seizures during alcohol withdrawal. These medications are rapid-acting and their effects often wear off within a few hours.

It’s often not possible to take a medication by mouth during a seizure, and the medications used for emergency management of seizures are available in forms that can be injected into a muscle (IM), administered intravenously (IV, in a vein), used as a nasal spray, or administered rectally. 

Rescue Seizure Medications 

A number of rescue seizure medications can be used to stop seizures. Several of these medications are benzodiazepines, which inhibit the activity of the nervous system, including the brain, by binding to and regulating the action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter.

In addition to stopping seizures, rescue seizure medications also cause tiredness, dizziness, and slowed thinking. They may also slow down breathing, potentially requiring medical respiratory support. The antiseizure effects and the side effects of rescue seizure medications generally stop after a few hours.

Ativan (lorazepam)

Ativan is a benzodiazepine. The oral form of this medication is used for treatment of anxiety disorders. For treatment of status epilepticus, the intravenous (IV, in a vein) form of Ativan is recommended at a dose of 4 milligrams (mg) at a rate of 2 mg/min for patients 18 years and older.

If the seizures stop, no further administration of Ativan is recommended. If the seizures continue or recur after 10 to 15 minutes, an additional 4 mg dose is administered at the same rate as the first dose.

Diastat (diazepam)

This benzodiazepine is a rectal gel that is administered in a weight-based recommended dose of 0.2-0.5 mg/kilograms (kg) of body weight, depending on age.

Valtoco (diazepam)

This benzodiazepine is administered as a nasal spray. It is indicated for acute treatment of seizure clusters in patients with epilepsy 6 years of age and older. Dosing is weight and age based. The recommended dose is a single intranasal spray of 5 mg or 10 mg into one nostril or 15 mg or 20 mg doses, which requires two nasal spray devices, one spray into each nostril.

If necessary, a second dose can be used at least 4 hours after the initial dose. No more than two doses should be used to treat a single episode and Valtoco should not be used more than every five days and it shouldn’t be used to treat more than five episodes per month.

Valium (diazepam)

This oral benzodiazepine is used in managing anxiety disorders and muscle spasms. It is also used as a rescue seizure treatment in select circumstances, when a person can safely take it by mouth.

Klonopin (clonazepam)

Klonopin is a benzodiazepine that is used in the treatment of anxiety disorders. It is also used to treat persistent, repetitive seizures that occur as part of Lennox-Gastaut syndrome and myoclonic epilepsy.

Nayzilam (midazolam)

This benzodiazepine nasal spray is indicated for acute treatment of seizure clusters in patients with epilepsy 12 years of age and older. The recommended dose is one 5 mg spray into one nostril. An additional 5 mg spray can be used into the opposite nostril after 10 minutes if necessary.

No more than two doses should be used for a single seizure cluster episode, and Nayzilan should not be used more than every three days and should not be used to treat more than five episodes per month

Midazolam is also available in a form that is injected IM.

Phenytoin

The oral form of this nonbenzodiazepine medication is used as a maintenance therapy, and the IV formulation is used to stop ongoing seizures in the medical setting. Dosing is typically weight-based.

Phenobarbital

This barbiturate medication interacts with GABA to control seizures. An oral formulation is used as maintenance therapy, and the IV form is used for emergency seizure control in a medical setting.

Keppra (levetiracetam)

This anticonvulsant is approved for treatment of seizures in adults and children ages four and older. It is indicated for certain types of epilepsy that are typically difficult to treat, including myoclonic epilepsy. It is available as a tablet and an oral solution.

Rescue Medications vs. Maintenance Therapies

Rescue medications are different from maintenance therapies, which are anti-epilepsy drugs (AEDs) that are taken on a regular ongoing basis to prevent seizures.

Most maintenance AEDs are taken orally (by mouth) and are not absorbed quickly enough to stop ongoing seizures. However, the injected formulations of some maintenance AEDs are sometimes used as rescue seizure medications. 

Indications

Rescue medications are often used in an emergency setting, such as in the hospital. In these situations, you can be monitored closely for side effects, such as slowed breathing, and you would have medical support as needed.

In some cases, such as when a person has frequent seizures despite the use of maintenance AEDs, the doctor might prescribe a rescue medication to take at home or at an assisted care facility. Usually, caregivers will be given detailed instructions about dosing and timing.

Rarely, a person who has seizures would be given instructions about how to self-administer a rescue medication during the pre-ictal stage of a seizure to prevent the seizure from progressing to the ictal phase.

Specific settings when rescue seizure medications may be needed include:

• Cluster seizures: These are intermittent, stereotypic episodes of repetitive seizure activity that occur within a short period of time. These events require medical attention, and the recommended treatment is a benzodiazepine. Nasal Valtoco, Nayzilam, and rectal diazepam gel are FDA-approved rescue medications for seizure clusters.
• Status epilepticus: This is a persistent prolonged seizure that does not improve on its own, and often persists despite treatment. Phenytoin and phenobarbital are approved for treatment of status epilepticus, and levetiracetam and benzodiazepines are often used as well.
• Neonatal seizures: Neonatal seizures can manifest with minimal obvious symptoms, although they are usually associated with electroencephalogram (EEG) evidence of seizure activity. Common treatments include levetiracetam and phenobarbital, with weight-based dosing.
• Alcohol withdrawal: Alcohol withdrawal seizures should be treated in a medical setting. Lorazepam with diazepam are recommended.
• Paramedics: Sometimes paramedics must begin antiseizure treatment on the way to the hospital, and IM midazolam is often used in this situation.

A Word From Verywell

Rescue medications can be a necessary part of managing seizures. In some situations, your doctor may recommend that you have a rescue medication with you in case a breakthrough seizure occurs—and would provide you with detailed instructions about when and how to use your rescue medication.

Rescue seizure medications are often used in the medical care setting when a seizure is occurring or to treat a prolonged seizure that won’t stop on its own.

emDOCs.net – Emergency Medicine EducationTreatment of Seizures in the Emergency Department: Pearls and Pitfalls – emDOCs.net

Author: Raul Hernandez, MD (EM Resident Physician, SUNY Downstate/Kings County Hospital) and Mark Silverberg, MD (EM Attending Physician and Associate Residency Director, SUNY Downstate/Kings County Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

Epidemiology

Seizure-related complaints comprise approximately 1% of all emergency department visits. [1] This includes patients with first-time seizures and those with an established history of epilepsy. The difference between epilepsy and initial seizures will be discussed in the next section. Acute and chronic causes exist as triggers of seizures and include acute intracranial hemorrhage, cerebral injuries/scars, tumors, infections, metabolic derangements, and, of course, congenital causes of epilepsy. [1] Increasing age also confers greater likelihood of seizures or electroencephalographic abnormalities. [3, 4]

Defining Seizures and Epilepsy

The timing of seizures in relation to triggers or the presence of a discernible trigger is the basis for their classification as provoked or unprovoked. Provoked seizures are those that occur within 7 days of an acute neurologic, systemic, metabolic, or toxic (e.g., visual, intoxication or detoxication) insult. Unprovoked seizures are either farther out than 7 days from any precipitating factor or are not associated with any discernible cause. [2]

In addition, not all seizures are of the generalized convulsive type. Other types of seizures may involve focality. That is they may display sensory and/or motor effects in only one area of the brain. These other types are absence, simple partial, and complex partial seizures. As you may already be aware, the difference between a simple and complex partial seizure is that alteration in consciousness occurs only with complex seizures. Consideration must be given to the development or presence of status epilepticus in patients presenting with the complaint of seizure regardless of the subtype. [5]

Status epilepticus has historically had many differing definitions. The American College of Emergency Physicians (ACEP) 2014 clinical policy on patients presenting to the emergency department with seizures define status epilepticus as either unremitting convulsive seizure activity lasting 20 minutes or more, or intermittent seizures without regaining full consciousness in between. They also state that a generalized convulsive seizure lasting for at least 5 minutes can been defined as constituting status epilepticus. [2] This continuous seizure activity can change, evolving from a convulsive state to a subclinical state due to fatigue or exhaustion of muscles.

As the name suggests, this type of status epilepticus is more difficult to diagnose since the most obvious part of the seizure — the convulsion — has ceased. This is especially true in patients already comatose upon arrival. Unfortunately, subclinical seizures also have a much worse prognosis than other types. [5] Diagnosing this type of seizure activity requires EEG analysis, a topic we will further explore later.

Finding the Cause

Rather than a pathophysiologic explanation of seizures, the focus of this section will be diagnostic strategies for the patient presenting with seizures. The best strategy, by far, is a good history and physical examination since up to fifty percent of patients who present with a first-time seizure are actually found to have had similar preceding episodes and can possibly be diagnosed with epilepsy. [4]

As mentioned previously, there are provoked and unprovoked seizures. In clinical practice it is often difficult to tell the two apart. However, sometimes provoked seizures are secondary to disease states with clinically overt signs and symptoms such as intoxication, withdrawal (ethanol, benzodiazepines), trauma, meningitis, psychiatric issues, and metabolic derangements (e.g., hypoglycemia). This is by no means an exhaustive list, and coming up with one would be difficult as there are numerous causes for seizures. Often the history and/or physical exam help raise suspicion for the cause of the seizure (e.g., fever, stiff neck and altered mental status preceding a seizure should raise suspicion for meningitis).

The American Academy of Neurology (AAN) states in their practice parameters that the diagnostic and therapeutic modalities for provoked and unprovoked seizures are different in that addressing provoked seizures appropriately means providing intervention for the acute process causing them, whereas with unprovoked seizure treatment is aimed at seizure control. [4]

Provoked Seizure, Back to Baseline

According to the ACEP clinical policy, patients who have had a first-time provoked seizure, are back to baseline, and are otherwise asymptomatic should be evaluated and treated appropriately for the cause of their seizure. Anti-epileptic medication, which in this paper are defined as preventive (e.g., levetiracetam) and not abortive (e.g., lorazepam), need not be initiated. [2] The underlying factor or factors that caused the seizure should be addressed with the understanding that this should remove the stimulus that caused the seizures in the first place. [4, 6]

First-time Provoked Seizure, Not Back to Baseline

Once again, the offending factor or factors need to be addressed in this population. This subset of patients is at higher risk of having seizure recurrence. [2] These patients represent a subset that could benefit from additional testing such as electroencephalography in addition to more standard labs and imaging. EEG may be normal in up to fifty percent of patients with an actual seizure. However, for some patients it may show important information such as the presence of status epilepticus that is not overt. [4] Which labs and whether to image should be determined by the suspected causative factor. For instance, in a patient with a history of cancer who has experienced a seizure without return to baseline, a computer tomographic scan of the head may show metastases or some other intracranial process. [6] Remember that alcohol and its lack (withdrawal) is considered a risk factor for seizures. [4, 9]

First-time Unprovoked Seizure, Back to Baseline

Though these adult patients have returned to mental baseline, they will still require testing for glucose and sodium levels, a pregnancy test in women of childbearing age, and either a computed tomography (CT) head scan or a magnetic resonance imaging (MRI) study of the brain. Initiating an anti-epileptic medication is left to the discretion of the physician by ACEP, but if it is a true unprovoked first-time seizure then no medication is necessary. This is because one seizure does not constitute the diagnosis of epilepsy, and early initiation of therapy does not seem to provide protection from development of future seizures in the long-term. If a history of stroke or other central nervous system insult can be elicited, it changes management drastically. The number needed to treat (NNT) for prevention of one additional seizure with antiepileptics in this setting is five. It is estimated that up to 50% of patients presenting for first-time seizures have had previous similar incidents, which at the current presentation would give very high suspicion for a diagnosis of epilepsy. If such history can be elicited, then it makes treatment after recurrent seizure presentation warranted. [2]

Regardless of history of previous CNS insult, CT of the head is an important test in these patients, as this study alone has been shown to change management in approximately ten percent of cases. It is unclear whether MRI is a better study than CT in these cases, and it is unclear whether it is strictly necessary to do imaging right away or if it can wait for an outpatient appointment. [4, 6] Of course, social circumstances must be taken into account when deciding whether to scan at presentation or have imaging done on an outpatient basis. [1-3, 9]

Short-term risk is not well-defined in this patient population. Most studies look at risk of repeat seizure in months or years but not days. Unfortunately no prospectively derived guidance exists, although an algorithm has been proposed, and the College of Emergency Medicine (United Kingdom) practice guidelines published in 2009 reflect this. They propose that a patient can be discharged to home after a first generalized seizure if the following all exist: normal glucose, CT head scan, electrocardiogram, renal function tests, electrolytes including calcium, and complete blood count. In addition, the patient must have no abnormal neurologic signs or symptoms after a full recovery, normal vital signs, good social support including established follow-up and good likelihood of the appointment being kept, and a responsible adult to watch the patient at home. [7, 8] The AAN practice parameters discuss the uncertainty of the value of an electroencephalogram in this group of patients but do recommend it as a valuable study, especially when done within the first 24 hours after a seizure. [4]

Repeat Unprovoked Seizure/History of Epilepsy, Back to Baseline

If this seizure is similar to previous seizures, then these patients require evaluation of their anti-epileptic drug levels (if measurable) and assessment of other triggering factors. Often patients will be controlled on their antiepileptics regimen even at subtherapeutic levels but will have other triggers (e.g., lack of sleep, changes in or new medications, vomiting) which cause breakthrough seizures. [6] If they have been non-compliant with their AEDs medications, then they can be given a loading dose. There are many different medications and each has its own dosing regimen. Thankfully ACEP clinical policy does include a table with many of these agents. [2] Of note, intravenous phenytoin and, to a lesser degree, IV fosphenytoin, are more likely to cause hypotension without any proven benefit in decreasing seizure recurrence.

If the presenting seizure is different from those in the past then a more comprehensive work up is warranted looking for inciting factors. Once triggering factors and medication compliance have been addressed these patients may be able to go home. [6]

First-time or Repeat Unprovoked Seizure, Not Back to Baseline

This is a patient with a truly unprovoked seizure that has either persistent altered mental status or continued seizure activity. In addition to a work-up including consideration of lumbar puncture, imaging, electrocardiogram, and labs as described above (first-time unprovoked seizures, back to baseline), these patients may warrant electroencephalography (EEG) if it is available. [2,3] Status epilepticus, which is discussed next, must be considered in addition to any underlying factors that may actually make this a provoked seizure.

Status Epilepticus

Status epilepticus (SE) is truly a medical emergency. This phenomenon can present secondary to absence, simple partial, complex partial, and generalized convulsive seizures. There are two types: convulsive and non-convulsive status epilepticus (NCSE). Non-convulsive can evolve from all four types of seizures. It can also sometimes be mistaken for a coma. [5] The most dangerous type of SE is termed subtle SE, a name referring to its lack of convulsive activity with continued seizure activity in the brain. SE develops from a generalized convulsive epileptic seizure. It can sometimes be refractory to therapy and may require intubation and placing the patient in a medicine induced coma. [5, 6, 13] Treatment strategies are described below but as for disposition, this should be carefully discussed with the patient’s own neurologist or primary care physician. Admission is normally warranted. [6]

Clinical Findings and the Electroencephalogram

The physical exam can reveal information that can raise suspicion for true seizure activity and also status epilepticus. Abnormal neurological examination, predisposing history (<6 months of age, closed head injury, recent cerebrospinal fluid shunt revision, malignancy, neurocutaneous disorder, focal onset of seizure, no history of alcohol abuse, history of cysticercosis, altered mental status, age greater than 65, and seizure lasting >15 minutes) are probably predictive of an abnormal CT study in this context. [9] Another study also found some clinical features that could be predictive of status epilepticus on physical exam. These are remote factors for a seizure (stroke, tumor, previous neurosurgery, dementia, and meningitis), GCS <15, and abnormal ocular movements (nystagmus, hippus, or sustained eye deviation in any direction). The individual sensitivity and specificity of each of these findings was low. However, the study authors report a combined sensitivity for “remote risk factors for seizures” and “eye movement abnormalities” of 100%. If the sensitivity truly is that high, it may provide a good screening test for which patients with altered mental status should receive an urgent EEG. [10]

Alcohol abuse should also prompt a physician to have higher suspicion for SE. For instance, one review found that alcohol abuse was related to the presentation of seizures in 20-40% of patients presenting to an emergency department. It also found that among patients with SE, up to 20% are likely withdrawing from alcohol. [6] A separate study by Zehtabchi et al. found that in ED patients with undifferentiated altered mental status, EEG abnormalities existed in 78% of subjects, and NCSE was detected in five percent. [3]

Imaging

CT scan is the most common brain imaging study performed on patients with first time seizures. A review article by the American Academy of Neurologists found treatment changed due to CT findings in 9-17% of patients. This review also found that patients with AIDS and a first seizure were commonly diagnosed with abnormalities via CT. Toxoplasmosis was a frequent finding. [9]

Although neurologists tend to prefer MRI over CT, there is no published data that shows superiority of MRI over CT. The practice parameters published by the AAN also state that CT is an adequate first brain imaging study for a patient with first-time seizure and even in some cases of repeat seizures. [4, 6]

Electrocardiogram

Although we tend to think of the brain first when we think of seizures, we should also be thinking about the heart. Surprisingly, it has been known for quite some time that seizures can cause dysautonomia leading to cardiac dysrhythmias. [11, 12] Equally important is remembering that seizures can be caused by ingestion of substances that affect the fast sodium channels such as tricyclic antidepressants and other toxins that may also affect the heart. [2, 6] An ECG is appropriate as a screening tool for seizure patients presenting to the emergency department. [6-8]

Lumbar Puncture

Lumbar puncture should not be done on every patient presenting to the ED with a seizure, especially if they are back to baseline. It should instead be done selectively on patients with persistently altered mental status, fever, meningismus, severe headache, localized neurological signs and/or symptoms, and immunosuppression. [4,6]

Pregnancy

A presentation of seizures during pregnancy should prompt a screening for eclampsia. The clinician should also ascertain if a history of epilepsy already exists for the patient or if it is a first-time provoked or unprovoked seizure due to the one of etiologies previously described. Most women do not experience an increase in seizures during pregnancy, but for those who do, it might be attributable to poor medication compliance (that can be exacerbated by vomiting related to pregnancy), inappropriate reduction of AEDs, and/or a decreased amount of sleep. [6, 15]

The same management strategies apply to pregnant patients, especially when the patient is experiencing status epilepticus. Treatment should proceed taking into account two things. First, during pregnancy measurable AED levels in the serum may decrease secondary to a physiologically predicted increase in volume of distribution, hepatic clearance, and renal clearance. Be aware that although measurable drug levels may be lower there may also be a higher level of free-drug levels due to the decrease in plasma proteins that also accompany the increased plasma volume. The second thing to know is that valproate should be avoided in pregnancy, as this AED has been shown to have a high rate of teratogenicity, especially in combination with lamotrigine. [6]

It is important that patients understand the risk of teratogenicity with AEDs. Therapy with one AED during pregnancy confers a three percent risk of fetal malformation, which is slightly above the background risk without AEDs. Therapy with two or more AEDs increases that risk to approximately 17%. Most severe malformations occur if the fetus is exposed in the early stages (first-trimester) to AEDs, and the risks associated with SE to both the mother and the fetus far outweigh the risks associated with AED therapy. [6,15]

Medications

Before starting the discussion of what seizure abortive medications can be given to a patient experiencing seizures, it is important to recall that some anti-epileptic medications (e.g., phenytoin, carbamazepine) can actually induce seizures in some patients. It is important to gather information about recent changes or new medications. If seizures began in your patient after administration of a new or increased dose of AED, then withdrawal of this medication is advisable followed by treatments described below to break any persistent seizure activity. [5]

First-Line Medications

Regardless of type of seizure, patients actively seizing should receive benzodiazepines according to both emergency medicine and neurology literature. [2, 5, 6, 13, 14] Please keep in mind that patients may suffer from hypotension and decreased respiratory drive when administered these medications. Cardiopulmonary monitoring should be in place. Prasad et. al compared many medications commonly given during status epilepticus and found that in the ED setting, lorazepam given IV decreases the chance that SE will continue and the chance of needing more medications to stop SE. They also found midazolam was “probably better” than lorazepam for pre-hospital treatment because it can be given IM, obviating the need for IV access, and confers decreased risk of hospitalization and intensive care unit admissions when administered in the field. Surprisingly, they also found some data suggesting levetiracetam IV works equally well as lorazepam IV at stopping seizures in the in-hospital setting with less propensity for causing issues such as hypotension and need for mechanical ventilation. However, because it was only found in one small study, the authors continue to recommend lorazepam IV as the initial treatment of choice over other benzodiazepines or phenytoin. [13] Because not all drugs are available at all times and because IV is not always a feasible route of administration, suggested dosing for three benzodiazepines are as follows [5, 6]:

• lorazepam 4 mg IV push over 2 minutes (may be repeated in 5-10 min if seizure activity continues)

• diazepam 10 mg IV or rectal (may be repeated as above)

• midazolam 10 mg IV (may also be given IM if no IV access)

Second-Line Medications

If benzodiazepines are ineffective at stopping seizure activity, a more nuanced approach is advocated by the AAN practice parameters. If the patient has a history of absence seizures and is in SE due to this phenomenon then bolus administration of valproic acid (25-45 mg/kg at a rate of 6 mg/kg/min) or phenobarbital (20 mg/kg at 50 mg/kg/min) is recommended. If the patient has a history of frontal or temporal lobe epilepsy and is in partial SE they may require phenytoin (15-18 mg/kg at 25-50 mg/min; rate not to exceed 50 mg/min) or an equivalent dose of fosphenytoin (at 150 mg/min). [5, 6] Note that phenytoin can cause hypotension when given IV. Fosphenytoin also causes this side effect but at a much lower rate. Patients being administered either medication should be on cardiopulmonary monitoring. Fosphenytoin is also safe to give IM, whereas phenytoin is very toxic to vascular walls and causes necrosis if it extravasates into surrounding tissue during IV administration. This is why phenytoin should only be administered IV when a large vein is utilized. Even so, limb edema, ischemia, and discoloration can still occur. For these reasons and the rapidity with which it can be infused, fosphenytoin is often preferred over phenytoin. [6]

Third-Line Medications

The third-line medications are very powerful and have side effects that are commensurate to their potency. These medications are anesthetics being dosed at induction levels, and intubation followed by mechanical ventilation will be necessary along with appropriate cardiopulmonary monitoring. [6] If the patient is suffering from subtle SE, then administer induction dose anesthetics as described below without delay. Success of GABAergic medications (i.e., benzodiazepines) in this patient population is compromised due to the modification of GABA A receptors from the continuous seizure activity, and a high failure rate of these medications should be anticipated. [5]

If patients with SPSE and CPSE do not respond to previously mentioned treatment, the next medications in the algorithm are phenobarbital 20 mg/kg or valproic acid at 25-45 mg/kg. The authors warn that some neurologists are reluctant to go beyond this point to medications such as propofol because they carry significant morbidity and mortality risks. However, they identify a population of young patients with no other comorbidities who may benefit from treatment with midazolam (0.2 mg/kg bolus and 0.1-0.4 mg/kg/hr infusion), propofol (2 mg/kg bolus and 5-10 mg/kg/hr infusion), and thiopental (2-3 mg/kg bolus and 3-5 mg/kg/hr infusion). They make these recommendations in acknowledgement of a greater than 50% recurrence rate of seizure activity in this population. [5, 6]

Claasen et al. [14] compared two of the medications mentioned above and one other: midazolam, propofol, and pentobarbital in the setting of refractory SE. They found that titration of these medications to EEG background (isoelectric or burst) suppression rather than simply suppression of seizures led to a lower frequency of breakthrough seizures with a higher rate of hypotension also occurring. The study excluded simple partial and absence SE. Unfortunately, no mortality benefit was found with these medications even if the titration goal of EEG background suppression was met.

Admit vs. Discharge

As discussed in the section “First-Time Unprovoked Seizure, Back to Baseline” above, there are some guidelines, albeit not prospectively tested, for who can be considered discharged to home. To recapitulate, patients who experienced an unprovoked seizure but are otherwise healthy, have normal vital signs, a normal glucose level, CT head scan, electrocardiogram, renal function tests, electrolytes including calcium, and a complete blood count may be considered for discharge. This only applies to patients without abnormal neurologic signs or symptoms who have fully recovered from their seizure. Good social support is important as well because the patient will need a responsible adult to watch them at home. Prior to the patient leaving the emergency room, follow-up should be secured for the patient and the physician should feel there is a good likelihood of the patient getting to that appointment. [7, 8]

Pitfalls in the Treatment of Seizures

• Forgetting your ABCs: if a patient is continually seizing they may not be able to protect their airway or ventilate properly. If intubation is required to properly oxygenate, there should be no delay of intubation. Cardiopulmonary monitoring should also occur, especially in light of the rare but possibly fatal dysautonomia that can accompany seizures. [6]
• Using long-acting paralytics can mask seizure activity and if one has been used then an EEG might be considered to monitor the patient for seizure activity. [1]
• The most common finding on ECG is sinus tachycardia, but more concerning arrhythmias can occur. An ECG can be performed once a patient is not convulsing to check for these arrhythmias. [11]
• Forgetting to do a fingerstick glucose test. This is a relatively inexpensive test that may save a lot of work-up, administration of unnecessary medications, and provides a simple solution (50 mg of dextrose preceded by thiamine if suspicion for malnutrition exists). [6]
• Just because a patient is not convulsing does not mean seizure activity has ended. Non-convulsive status epilepticus exists and should be suspected until ruled out. [1-7, 10] 5 minutes of continual seizure activity define status epilepticus in the clinical setting because damage to brain cells can occur within this short time span, even in the absence of convulsions. [6]
• Phenytoin/fosphenytoin may not appropriately treat toxin-induced seizures because these AEDs work on sodium channels, not GABA receptors. This is most important to remember with alcoholics, who have the highest early seizure recurrence. Other medications that can cause the same type of resistance during a detoxication phase are benzodiazepines. [2]
• Do not assume the seizure is solely due to low levels of AEDs which can be measured. Instead seizures might be due to other stressors (lack of sleep, metabolic derangements, vomiting in pregnant women, etc.). Though if measured levels are low consideration of a loading dose is appropriate. [2, 5]
• Though there is no strong data to support or refute the practice, a lumbar puncture on immunocompromised patients can find occult intracranial infection. [4, 6]
• Know if your state requires mandatory reporting by physicians of patients with seizures to the DMV. It is important to stay compliant with this law if it exists where you practice. [6]

References/Further Reading

1. American College of Emergency Physicians. Clinical policy: critical issues the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2004;43:605-625.
2. Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63(4):437-447.
3. Zehtabchi S, Abdel Baki SG, Omurtag A, et al. Prevalence of non-convulsive seizure and other electroencephalographic abnormalities in ED patients with altered mental status. Am J Emerg Med. 2013;31(11):1578-1582.
4. Krumholz A, Wiebe S, Gonseth G, et al. Quality Standards Subcommittee of the American Academy of Neurology; American Epilepsy Society. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007 Nov 20;69(21): 1996-2007.
5. Meierkord H, Holtkamp M. Non-convulsive status epilepticus in adults: clinical forms and treatment. Lancet Neurol. 2007;6(4):329-339.
6. Teran F, Harper-Kirksey K, Jagoda A. Clinical decision making in seizures and status epilepticus. Emerg Med Pract. 2015 Jan;17(1):1-24; quiz 24-5.
7. Turner S, Benger J, for the College of Emergency Medicine (UK). Guideline for the management of first seizure in the emergency department. The Guidelines in Emergency Medicine Network (GEMNet). December 2009.
8. Dunn MJ, Breen DP, Davenport RJ, Gray AJ. Early management of adults with an uncomplicated first generalised seizure.
9. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;69(18):1772-1780.
10. Husain AM, Horn GJ, Jacobson MP. Non-convulsive status epilepticus: usefulness of clinical features in selecting patients for urgent EEG. J Neurol Neurosurg Psychiatry 2003; 74: 189–91.
11. Allana SS, Ahmed HN, Shah K, Kelly AF. Ictal bradycardia and atrioventricular block: a cardiac manifestation of epilepsy. Oxf Med Case Reports. 2014 May 19;2014(2):33-5. doi: 10.1093/omcr/omu015. eCollection 2014 May.
12. Britton JW, Ghearing GR, Benarroch EE, Cascino GD. The ictal bradycardia syndrome: localization and lateralization. Epilepsia. 2006 Apr;47(4):737-44.
13. Prasad M, Krishnan PR, Sequeira R, Al-Roomi K. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev. 2014 Sep 10;9:CD003723.
14. Claassen J, Hirsch LJ, Emerson RG, et al. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. 2002;43(2):146-153.
15. Crawford P. Best practice guidelines for the management of women with epilepsy. Epilepsia. 2005;46 Suppl 9:117-24.
16. http://www.ncbi.nlm.nih.gov/pubmed/25377404

Status Epilepticus | Johns Hopkins Medicine

What is status epilepticus?

A seizure involves abnormal electrical activity in the brain affecting both the mind and the body. Many problems can cause you to have a seizure. These include high fever, brain infections, abnormal sodium or blood sugar levels, or head injuries. If you have epilepsy, you may have seizures repeatedly.

A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death.

Status epilepticus is very rare, most people with epilepsy will never have it. This condition is more common in young children and elderly adults.

This condition can occur as:

• Convulsive status epilepticus. Status epilepticus with convulsions may be more likely to lead to long-term injury. Convulsions may involve jerking motions, grunting sounds, drooling, and rapid eye movements.
• Nonconvulsive status epilepticus. People with this type may appear confused or look like they’re daydreaming. They may be unable to speak and may be behaving in an irrational way.

What causes status epilepticus?

In children, the main cause of status epilepticus is an infection with a fever. In adults, the common causes include:

• Stroke
• Imbalance of substances in the blood, such as low blood sugar

• Drinking too much alcohol or having alcohol withdrawal after previous heavy alcohol use

Who is at risk for status epilepticus?

There are many risk factors for status epilepticus including:

• Poorly controlled epilepsy
• Low blood sugar
• Stroke
• Kidney failure
• Liver failure
• Encephalitis (swelling or inflammation of the brain)
• HIV
• Alcohol or drug abuse
• Genetic diseases such as Fragile X syndrome and Angelman syndrome
• Head injuries

What are the symptoms of status epilepticus?

These are possible symptoms of status epilepticus:

• Muscle spasms
• Falling
• Confusion
• Unusual noises
• Loss of bowel or bladder control
• Clenched teeth
• Irregular breathing
• Unusual behavior
• Difficulty speaking
• A “daydreaming” look

How is status epilepticus diagnosed?

Your healthcare provider will do a thorough physical exam and ask about your health history, any medicines you are taking, and if you’ve been using alcohol or other recreational drugs.

Your healthcare provider may also order an electroencephalogram. This involves placing painless electrodes onto your scalp to measure the brain’s electrical activity.

You may need other tests to search for possible causes. These include a lumbar puncture (spinal tap) to look for signs of infection. A CT scan or MRI may be needed to see problems in the brain.

How is status epilepticus treated?

The healthcare provider will want to end the seizure as quickly as possible and treat any underlying problems that are causing it. You may receive oxygen, have blood tests, and an intravenous (IV) line. You may be given glucose (sugar) if low blood sugar may be causing the seizure.

Healthcare providers may use anti-seizure drugs to treat the problem, including:

• Diazepam
• Lorazepam
• Phenytoin
• Fosphenytoin
• Phenobarbital
• Valproate

These drugs are given through an IV or an injection into a muscle.

What are the complications of status epilepticus?

Complications depend on the underlying cause and can range from no complications to death. If the underlying cause, such as poor epilepsy control, can be fixed, there may no complications. If the underlying cause is a stroke or brain injury, complications may include physical disability from the cause or even death.

Can status epilepticus be prevented?

If you have epilepsy, taking your medicines as directed may help you avoid status epilepticus. If you’ve had status epilepticus, you may need to begin taking seizure medicines or change medicines you’re already taking. Avoiding other causes of this condition, such as alcohol abuse or low blood sugar, may also help prevent it.

Key points about status epilepticus

• Status epilepticus has many causes. Some can be prevented such as low blood glucose or alcohol and drug abuse.
• Individuals who have epilepsy must take their medicine as directed.
• A seizure that lasts more than 5 minutes, or having more than 1 within a 5 minute period is an emergency that requires immediate medical care.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

Epilepsy emergency medication | Epilepsy treatment

A seizure is not normally a medical emergency and the vast majority of seizures stop by themselves without the need for any treatment. However sometimes a medical emergency known as status epilepticus can occur.

Status epilepticus

This is defined as any seizure involving unconsciousness lasting for 30 minutes or longer; or repeated seizures lasting for 30 minutes in total from which the person does not regain consciousness between each seizure.

Although any type of seizure may develop into status epilepticus, generalised tonic clonic seizures progressing into status epilepticus are the most serious.

The longer a seizure continues, the harder it is to stop. So best practice is to treat a generalised tonic clonic seizure with emergency medication after five minutes. This is also known as rescue medication.

Epilepsy emergency medication may be prescribed if a child has previously experienced a seizure that has lasted for five minutes or more. An action plan should be agreed with the doctor so that you know what to do in an emergency situation. This should be shared with the child’s school and staff who will administer the medication need to be trained to do so.

Emergency drugs have an anticonvulsant effect and can stop seizures. Midazolam and Diazepam are the two most commonly used.

Midazolam

Midazolam is a liquid rescue medication that is released into the mouth between the cheek and the gums (known as the buccal cavity). The advantages of Midazolam are that it does not cause prolonged drowsiness (normally only 24 hours) and it is very easy to administer during a seizure.

Very occasionally Midazolam can cause breathing difficulties. If this happens, call 999.

Diazepam

Diazepam is a rescue medication that is given via the rectal route (into the bottom).

Information on how to administer it is included in the packaging but a nurse will usually talk it through with parents. Any school staff who may need to administer medication will need training.

Rectal Diazepam may be difficult to administer if the child is in a wheelchair, or getting them in a suitable position to give the medication during a seizure.

Other problems include if the child is constipated or their bowels open when it is given, which can mean that an incorrect dose is administered.

The child will be drowsy after receiving the medication and this can continue for 12 hours or more. Very rarely breathing difficulties may occur, but if this does happen, call an ambulance immediately.

Young Epilepsy can provide emergency medication training for schools and other settings. Please email This email address is being protected from spambots. You need JavaScript enabled to view it. for more details.

Management of Status Epilepticus – American Family Physician

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Drug treatment of epilepsy, drugs and medicines

Epilepsy is associated with the emergence of a persistent focus of excitation in the human brain. A large group of closely spaced neurons (the main functional cells of the brain) generate electrical potentials too actively, and they then spread to other parts of the brain 2.

In order to understand how AEDs work, a few words must be said about signal transmission between neurons.An electrical signal travels along a nerve fiber. The current in the fiber is generated by the alternating opening and closing of ion channels on the cell surface. When sodium and calcium enter a nerve cell through specialized channels, and potassium seeks to leave it, a difference in charges appears on the neuron membrane, which is a nerve signal transmitted along the nerve fiber. When an electrical discharge reaches the end of a nerve fiber, a neurotransmitter, a special substance that transmits a signal to another neuron, begins to be released from it into the synaptic cleft.A neurotransmitter can excite a cell (for example, glutamate) or reduce its activity (gamma-aminobutyric acid, abbreviated as GABA) 3.

AEDs are able to influence different stages of the described process and thereby normalize the work of neurons. AED can be divided into groups according to their mechanism of action as follows:

• Sodium channel blockers:

  • Lamotrigine prevents the excessive release of excitatory glutamate and prevents the already released neurotransmitter from causing an electrical signal in the cell 4.
  • Carbamazepine blocks sodium channels on the surface of the neuron, preventing further transmission of signal 4;

• Influencing GABA:

  • Phenobarbital and tranquilizers (diazepam) make GABA receptors more sensitive, which increases its “sedative” effect 4;

• Calcium channel blockers:

  • Ethosuximide blocks calcium channels, which also prevents the propagation of the signal along nerve fiber 4;

• Modulators of protein 2A synaptic vesicles:

  • Levetiracetam enhances the effect of neurotransmitters that reduce neuron excitation and is assumed to have a complex mechanism of action 4;

• Drugs with multiple mechanisms of action:

  • The effect of topiramate is mainly to increase the inhibitory effect of GABA on nerve cells 4.
  • Valproic acid increases the amount of GABA in the central nervous system, however, the mechanism of action of valproic acid is not fully understood and it is assumed that it has a complex mechanism of action 4;

All AEDs can be divided into two large groups – traditional (basic) drugs and the so-called new drugs obtained relatively recently.At the same time, it cannot be said unequivocally that the new drugs are better than the traditional ones; the drugs that were synthesized earlier have been studied in more detail. Doctors are well aware of their side effects and interactions with other drugs. the emergence of new molecules is associated with the search for drugs for those cases where traditional drugs did not work. Nowadays, new drugs are often used as an adjunct to the main therapy to the base drug. 8

Antiepileptic drugs (AEDs) are one of the treatments for epilepsy.The most common forms of release are capsules, tablets and granules for oral administration. They, in turn, are divided into drugs of immediate and sustained release. The former have an important disadvantage: a rapid rise in the concentration of the drug and its subsequent decrease. As a result, the drug has a stronger effect on the body at the beginning of its stay in the body, but it decreases rapidly after reaching the peak concentration. With a subsequent decrease in the content of the drug in the blood, its effect on the central nervous system decreases 5.

Sustained-release tablets do not have the disadvantage described above. The active substance is arranged in several layers on a special basis. Dissolving, such a tablet gives rise to new portions of the drug. At the same time, its concentration is maintained for a long time 5. Sustained-release drugs can reduce the frequency of taking the pills. This has two important implications for the treatment of epilepsy.Firstly, it becomes more convenient for the patient to follow the doctor’s prescriptions, that is, the adherence to therapy increases, due to the decrease in the number of pills taken. Secondly, this form of release allows better control of the disease, due to the absence of peaks in the concentration of the drug in the blood, and its rapid fall. As a result, changing the form of the drug taken improves the process of treating the disease. In addition to sustained-release tablets, there are also granules with a similar principle of action. Sustained-release granules can be sprinkled in liquids or semi-liquid foods (yoghurts) to facilitate administration in children and those with swallowing difficulties 6.

Among the dosage forms in which AEDs can be given, there are not only tablets and capsules. A special place in the therapy of epilepsy is occupied by drugs in the form of a solution, syrup or drops, which are convenient to use in pediatric practice. They swallow better as they are liquid. Some of the drugs may have a syringe for dosing the drug or special measuring spoons in the kit. These devices make it possible to simplify the process of taking the drug, and with a certain amount of imagination, even turn it into a game.The syrup form can also be used in patients with limited swallowing.

There are injectable drugs used to quickly stop an epileptic seizure or a series of them, as well as in cases where the use of other forms is impossible. These drugs are commonly used in hospitals and ambulance teams.

Road Clinical Hospital

Epilepsy is a chronic disease characterized by a tendency to recurrent sudden seizures.Based on the achievements of modern science, it has been shown that an epileptic seizure occurs as a result of disturbances in the processes of excitation and inhibition in the cells of the cerebral cortex. Epilepsy is a potentially curable disease. According to world statistics, the use of modern antiepileptic drugs allows 65% of patients to get rid of seizures and significantly block the number of seizures in another 20%. Epilepsy is one of the most common diseases of the nervous system, which, due to its characteristics, presents a serious medical and social problem.

Symptoms.

There are about 40 different forms of epilepsy and different types of seizures. The doctor must conduct the necessary examination and accurately diagnose the form of epilepsy and the nature of the seizures. Moreover, for each form there is a specific antiepileptic drug and its own treatment regimen. Attacks can be accompanied by loss of consciousness, development of respiratory failure, cramps in the limbs. Possible bite of the tongue or cheeks, loss of urine.Seizures usually last from a few seconds to a few minutes and resolve spontaneously. Attacks can be accompanied by partial loss of consciousness, sensory disturbances in a certain part of the body, and fading. During a seizure, chewing, laughing or smiling, licking lips are often observed, the patient can kick, fiddle with clothes. The movements are usually coordinated, but repetitive and stereotyped; the patient does not perceive others. There are also seizures without impairment of consciousness in the form of a feeling of fear, the appearance of stereotypical obsessive thoughts, the appearance of an unusual taste, smell, or a feeling of what has already been seen (as if something of what was happening had been seen before).The memory of the attack is often missing.
If the seizure continues for hours without a break, or the seizures follow each other, and in the interval between them consciousness is not fully restored, then they speak of the development of status epilepticus in the patient. Although the status can be associated with any type of seizure, life threatening occurs only with generalized seizures and respiratory distress. Mortality in status epilepticus reaches 5-15%. If prolonged, secondary brain damage occurs in more than 50% of cases.In view of this threat, a patient with prolonged seizures needs urgent medical attention.

Treatment.

Epilepsy is treated in four areas:
1) prevention of seizures with the help of medicines;
2) elimination of factors (situations or substances) that provoke seizures;
3) social rehabilitation of the patient, contributing to his transformation into a full-fledged member of society;
4) counseling the patient’s family and friends in order to develop the correct attitude towards him and his illness.Sometimes it is possible to identify specific causes of seizures that can be blocked with medication or surgery. The majority of patients need to take anticonvulsant (antiepileptic) drugs for life.

Treatment is carried out by: Neurological Department

90,000 Treatment of epilepsy in Moscow for children and adults at the EMC clinic

At Epilepsy Center of the Clinic of Neurology and Neurosurgery of the European Medical Center, diagnostics and treatment of epilepsy in pediatric and adult patients is carried out according to the most modern European and North American protocols.

Diagnosis of epilepsy in EMC

Patient management is carried out by neurologists-epileptologists, who are among the best specialists in this field. Specialists in hereditary genetic diseases, neuropsychology and other specialists take part in the diagnosis of patients with epilepsy.

EMC conducts all necessary research, including antiepileptic drug concentration testing and basic genetic testing.

Patients with epilepsy undergo electroencephalography (EEG) and long-term video-EEG monitoring (day, night, daily, multi-day). To diagnose the structural causes of epilepsy, we conduct an MRI scan using an epileptological scan program.

In special cases, for patients with epilepsy, PET (PET) and SPECT (SPECT) are performed in our clinic to identify the focal source of epileptic activity.

Epilepsy Treatment in EMC

Examination and further treatment of patients with epilepsy under the supervision of experienced epileptologists is carried out according to a well-established protocol.The main observation takes place on an outpatient basis at the EMC Children’s Clinic on the street. Trifonovskaya, a multifunctional medical center EMC in Orlovsky lane and a multidisciplinary hospital EMC on the street. Shchepkina. If necessary, the patient can be hospitalized, for example, for some studies or when the patient is in serious condition.

Patients who are observed in our clinic can be calm, because even in emergency cases, they can be helped 24 hours a day: the clinic has an ambulance service with resuscitation teams, an emergency and emergency department, a neuroreanimation department and the duty personnel of neurological and neurosurgical services …

In cases of focal epilepsy or drug-resistant forms of epilepsy, after a special preoperative examination, patients can undergo neurostimulation techniques and neurosurgical treatment by highly qualified EMC neurosurgeons.

What is epilepsy?

Seizures are often seen in children and adults. According to the World Health Organization, up to 10% of the world’s population experience at least one seizure during their lifetime.Most often, seizures are noted in childhood and old age.

Epilepsy is a chronic disease accompanied by repeated convulsive and non-convulsive seizures due to excessive electrical discharges in the brain. There are many forms of epilepsy with different clinical manifestations and caused by many reasons – from hereditary diseases to the consequences of brain injury. Currently, a separate direction in neurology has emerged that studies the patterns of occurrence, development and treatment of epilepsy – epileptology.A neurologist who specializes in the diagnosis and treatment of epilepsy is called an epileptologist.

What do epileptic seizures look like?

There are dozens of types of seizures described in the special literature, and even more – their combinations, so it is worth limiting ourselves to the basic concepts. The most famous are the so-called generalized tonic-clonic seizures with loss of consciousness, tension and twitching throughout the body. In addition, there are myoclonic seizures, which are short jerks throughout the body or in any part of it, often without changing consciousness – for example, jerking hands with objects falling out of them, or a sudden fall, as from a blow under the knees.

Tonic seizures are manifested by sufficiently prolonged muscle tension in any part of the body.

In children, an attack can often look like tension and tremors of the hand, half of the face with speech impairment while still conscious.

At an early age, special seizures are often observed – spasms that look like short-term episodes of jerking with limb spreading or, conversely, “squeezing into a ball”, arising in the form of a series, when the spasms are repeated several times over a short time.

One of the most common types of seizures is absences, in which the child freezes and does not respond to treatment. An important sign is the asymmetry of movements during an attack, for example, turning the head and eyes to the side, raising and straining one arm, twitching the corner of the mouth on one side. This may indicate the focal nature of the seizure, that is, its connection with a specific limited area of ​​the brain.

It is very important to remember the patient’s appearance during the attack, it is even better to record the attack on video, a mobile phone camera is enough.Typical seizure patterns often provide an early assessment of prognosis and the need for and feasibility of treatment.

Are seizures always associated with epilepsy?

Not at all necessary. Paroxysmal states of various kinds – convulsive and non-convulsive – can occur with an increase in temperature (febrile convulsions), poisoning, dehydration, head trauma, and cerebrovascular accident. In addition, outwardly it is difficult to distinguish fainting, sleep disorders, some forms of migraine, various movement disorders, “psychological” disorders from convulsions.An important difference between paroxysms in most of the listed disorders from epileptic seizures is the connection with a provoking factor or acute damaging effect (trauma, poisoning, overheating). In epilepsy, seizures in most cases are spontaneous or are caused by simple stimuli (flickering of light, deep forced breathing).

What to do in case of a seizure attack?

In most cases, seizures resolve on their own within seconds or minutes.Regardless of the cause of the attack, first aid is only to prevent injury and ensure free breathing. During an attack, the patient should be away from heavy, unstable, stabbing and cutting objects. Do not hold the patient forcibly. In no case should you try to unclench your jaws and take out your tongue – this is useless.

To ensure the patency of the airway, it is enough to lay the patient on his side with the face turned down. In this position, the tongue will not sink and block the breath.Attempts to unclench the teeth often end in injuries, tooth fragments can enter the respiratory tract and cause respiratory arrest, or even death. It is usually impossible to avoid biting the tongue after the onset of an attack, and attempts to reach the tongue only lead to additional injuries. It is useless to give a person in a convulsive attack artificial respiration and heart massage.

Thus, all that is needed is to move the dangerous objects away from the patient, put him on his side, face down, and call 03.At the same time, it is advisable to remember about the recommendation of video filming of events, this can be done by an assistant.

After the end of the attack, the patient should be allowed to rest, drowsiness is possible. It is necessary to make sure that the patient has come to his senses, is oriented in the environment, there are no speech disorders and movements in the limbs are preserved (ask to answer simple questions, raise and hold arms and legs). Until the complete disappearance of impaired consciousness, nothing should be given to eat or drink in order to exclude the ingestion of food, water or drugs into the respiratory tract.

For some types of seizures (for example, absences and infantile spasms), emergency care at the time of the seizure is often not required.

When is epilepsy treatment prescribed?

Traditionally, it is believed that after a single convulsive attack, you can refrain from treatment, since the attack may remain the only one in your life. In a real-life situation, the doctor may suggest treatment after a single episode if there are convincing signs of a high risk of subsequent seizures – for example, abnormalities on neurological examination combined with changes on tomograms and electroencephalograms.

Anticonvulsants are prescribed only when it is certain that the patient has epilepsy. If the diagnosis is unclear and the patient feels normal outside of the attack, then it is quite acceptable to refrain from treatment and do the necessary examinations, even if the attack recurs. According to current data, immediate prescription of drugs does not affect the long-term effect of treatment.

How is epilepsy treated?

First of all, antiepileptic drugs.The standard rule of thumb is that treatment should start with a single broad-spectrum drug. If the prescribed drug is not effective enough, then another drug is prescribed, taking into account the type of seizure, the form of epilepsy, the presence of concomitant diseases. In the absence of seizures and serious side effects, treatment continues continuously for several years, after which a complete withdrawal of drugs is possible.

In severe cases, steroid hormones, a ketogenic diet, or neurosurgery are added to the base drugs.

What tests are needed for epilepsy?

First of all, electroencephalography (EEG). Only on the EEG can you see a picture of the electrical activity of the brain and its changes associated with epileptic seizures. That is, the EEG tells the doctor whether the patient has epilepsy, and if so, what is its form.

Specific EEG changes characteristic of epilepsy are called epileptiform activity. There are a lot of types of this activity, epileptologists can in some cases make a diagnosis by EEG without additional examinations.However, there are situations when no changes are visible on the EEG, despite the existing seizures. In such cases, repeated studies are performed or a long-term EEG recording is prescribed. Usually, long-term EEG studies with video recording are combined with the term “EEG video monitoring”. Such a study can be performed for several hours and days, depending on the characteristics of a particular patient.

In addition to EEG, in most cases, magnetic resonance imaging (MRI) of the brain is used.MRI does not “show the presence of epilepsy,” but it helps to see the structure of the brain and identify the damaged “areas” in which the seizure is generated. These “areas” can be tumors, congenital anomalies, changes after trauma and circulatory disorders, etc.

In many cases, instead of or in conjunction with MRI, computed tomography (CT) of the brain is used, but its possibilities are not so wide.

To find the causes of epileptic seizures or to be able to distinguish some seizures from others, the doctor may prescribe other examinations, but EEG and MRI are standard.

What are the restrictions for patients with epilepsy?

In the absence of frequent seizures or mental disorders against the background of any progressive illness, children with epilepsy can attend children’s institutions, and in the future receive secondary and higher education.

Traditionally, many patients exclude sports activities on equipment (for example, on a rope) and in the water. If epileptic seizures in a patient can be provoked by something (lack of sleep, rhythmic flickering light), then it is the provoking factors that limit it (for example, visiting discos).Sometimes, with sensitivity to light flashes, it is forbidden to work on computers and watch TV, although usually it is enough to follow simple rules – not to watch TV in the dark and not to turn on entertainment programs with often flickering images, or to watch episodes with flickering, closing one eye. In addition, with the proliferation of liquid crystal displays, the risk of flickering has decreased. The covers of videos and computer games often indicate the presence of scenes that can provoke seizures.

In general, it is quite possible for patients with achieved control over seizures to exercise, watch TV, and work on a computer.

In a stable situation, when the diagnosis is clear, seizures have disappeared during therapy, or do not progress, vaccination is usually not contraindicated.

People with epilepsy can fly by plane. Precautions include strict adherence to the medication regimen and, if possible, enough sleep on the days associated with the flight, so as not to provoke an attack of lack of sleep.

Can epilepsy go away without treatment?

Yes, there are several forms of epilepsy with an absolutely favorable prognosis. This primarily applies to rolandic and benign occipital epilepsies. Seizures in children with these forms usually disappear by adolescence. However, this does not mean that they do not need to be treated – attacks can be very difficult, even requiring resuscitation. Some experts do not consider it necessary to treat Rolandic epilepsy for rare seizures, but this position has recently been disputed by many epileptologists.

In some other forms, a favorable outcome with spontaneous recovery is also possible, but it can be extremely difficult to predict it.

Is it possible to prevent epilepsy?

No, it is impossible to predict the occurrence of epileptic seizures if they have never happened. Even if you take an EEG and see epileptiform activity, the likelihood of seizures will remain unclear – many healthy people have pathological EEG changes that do not manifest themselves in any way.

Epilepsy | Symptoms, complications, diagnosis and treatment

Epilepsy is a disorder of the central nervous system (neurological) in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensation, and sometimes loss of consciousness. Epilepsy affects both men and women of all races, ethnic groups and ages. The symptoms of seizures can vary greatly. Having one seizure does not mean you have epilepsy.At least two unprovoked seizures are usually needed to diagnose epilepsy.

Medication or sometimes surgery can control seizures in most people with epilepsy. Some people need lifelong treatment to control their seizures, but for others, the seizures eventually go away.

Because epilepsy is caused by abnormal activity in the brain, seizures can affect any process that the brain coordinates. Signs and symptoms may include:

• Temporary confusion
• Uncontrolled jerking movements of arms and legs
• Loss of consciousness or understanding of reality
• Mental symptoms such as fear, anxiety or deja vu

Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will have the same type of seizure each time, so the symptoms will be similar from episode to episode.

Epilepsy has no identifiable cause in about half of people with the condition. In the other half, the conditions of occurrence of the disease can be attributed to various factors, including:

• Genetic influence. Researchers have linked some types of epilepsy to specific genes, but for most people, genes are only part of the cause of epilepsy. Certain genes can make a person more sensitive to environmental conditions that cause seizures.
• Head injury. Head injury from a car accident or other causes can cause epilepsy.
• Brain states. Brain conditions that cause brain damage, such as brain tumors or strokes, can cause epilepsy. Stroke is the leading cause of epilepsy in adults over 35.
• Infectious diseases. Infectious diseases such as meningitis, AIDS and viral encephalitis can cause epilepsy.
• Prenatal trauma. Before birth, babies are susceptible to brain damage, which can be caused by several factors, such as an infection in the mother, poor nutrition, or lack of oxygen. This brain damage can lead to epilepsy or cerebral palsy.
• Developmental disorders. Epilepsy can sometimes be associated with developmental disorders such as autism and neurofibromatosis.

Alcoholic epilepsy

Alcoholic epilepsy is a group of pathological conditions in which convulsive or non-convulsive seizures are observed associated with alcohol consumption.It develops more often in patients with alcoholism. Sometimes it occurs with one-time alcoholic excesses in people who do not suffer from alcohol dependence. Refers to the group of symptomatic epilepsies. May be accompanied by seizures, automatic actions and impaired consciousness. Treatment includes avoiding alcohol altogether and taking anticonvulsants.

Alcoholic epilepsy

Alcoholic epilepsy is a type of symptomatic epilepsy that occurs in connection with the use of alcohol.It usually develops in the II-III stage of alcoholism. In some cases, it can be observed with occasional intake of large doses of alcohol. Includes several pathological conditions accompanied by convulsive or non-convulsive seizures. More often observed in men aged 30-40 years. The characteristic features of this pathology are a clear connection between seizures and episodes of alcohol intake, a high frequency of non-convulsive seizures, and the absence of epileptic signs on the EEG.

Seizures from falling or hitting hard objects can cause injuries of varying severity.Before the onset of a seizure, sudden changes in mood are possible, accompanied by aggression towards others. Seizures in chronic alcoholism are often harbingers of alcoholic delirium (delirium tremens). The treatment of this disease is carried out by specialists in the field of narcology in cooperation with epileptologists.

Causes of development and classification of alcoholic epilepsy

The main cause of development is damage to brain cells as a result of the toxic effects of alcohol.The likelihood of seizures increases with prolonged binge drinking, the intake of low-quality alcoholic beverages and alcohol-containing liquids that are not intended for internal use. Other risk factors include craniocerebral trauma (both recent and recent), hereditary predisposition to epilepsy, cerebrovascular accident, infectious diseases and brain tumors.

Currently, there is no separate nosological category “alcoholic epilepsy” in the ICD.Convulsive and non-convulsive seizures that have arisen in connection with alcohol use are considered within the framework of other diagnostic categories, for example, “alcohol intoxication with a convulsive attack,” “withdrawal symptoms with a convulsive attack,” etc. epilepsy “can be used to determine several pathological conditions: epileptic reaction, epileptic syndrome and true alcoholic epilepsy.

• Epileptic reaction – single or episodic seizures that occur against the background of one-time alcoholic excesses in people who do not suffer from chronic alcoholism.The attack usually develops the next day after drinking. After the signs of a hangover disappear, the attacks stop.
• Epileptic syndrome is more widespread than alcoholic epilepsy. Observed in chronic alcoholism. It is characterized by the presence of repeated seizures. It is accompanied by mental and somatic disorders inherent in alcoholism. During seizures, in some cases, auras that resemble illusions or hallucinations may occur.
• Alcoholic epilepsy rarely develops, usually against the background of prolonged continuous use of alcoholic beverages (from 10 years or more) and accounts for about 10% of the total number of epileptiform seizures caused by alcohol consumption.Attacks usually occur during withdrawal symptoms and often turn into alcoholic psychosis.

Symptoms and diagnosis of alcoholic epilepsy

In true alcoholic epilepsy, there is a similarly pronounced relationship between an attack and alcohol consumption as between alcohol consumption and the development of withdrawal symptoms or alcoholic psychosis. All of these pathological conditions, as a rule, do not occur during the period of active use, but some time after the cessation of alcohol intake.Most often, epileptic seizures appear 2-4 days after the cancellation or significant reduction in the dose of alcohol, at the peak of the withdrawal syndrome.

Both convulsive and non-convulsive seizures are possible. The nature and severity of seizures can vary – from short-term disturbances of consciousness to serial tonic-clonic seizures and seizures with the development of status epilepticus. Non-convulsive seizures are noted more often than convulsive seizures and may be accompanied by motor automatisms, impaired consciousness, or episodes of pronounced dysphoria.A distinctive feature is the absence of polymorphism – once having arisen, the seizures proceed according to the same pattern, without changing the clinical picture.

With convulsions, the predominance of the tonic phase is noted. Absences (short-term “shutdowns” of consciousness), psychosensory (ringing, feeling of discharge or flash) and psychomotor (changes in consciousness in combination with convulsions or motor automatisms) attacks are rare. Before the onset of a generalized seizure, there is a pallor and cyanosis of the upper body.During an attack, the patient falls, throws back his head, strongly (often – until gnashing) clenches his teeth, groans, bends his arms and legs. Respiratory problems and involuntary urination are possible.

Some types of epileptic seizures are not recognized by others due to unusual symptoms unknown to people who are far from medicine. Among such attacks are sudden stops of speech, as well as pronouncing words or phrases that are inappropriate for the occasion that do not correspond to the topic of conversation and are not retained in the patient’s memory.Sometimes seizures occur against the background of precursors (dysphoria, a sharp increase in anxiety and irritability), which others take for signs of alcohol withdrawal.

A distinctive feature is some features of the state and behavior of patients in the post-attack period. Patients with idiopathic epilepsy usually feel tired, lethargic, and overwhelmed after seizures. Less often, there is a phase of twilight clouding of consciousness or psychomotor agitation.In patients with alcoholic epilepsy, after a seizure, sleep disturbances occur: insomnia, frequent nocturnal and early awakenings, and emotionally intense fantasy dreams.

In 50% of patients suffering from seizures due to alcohol use, against the background of insomnia 1-2 days after the attack, delirium develops, accompanied by vivid visual hallucinations, in which there are devils, aliens, fantastic creatures, etc. Over time, the seizures do not worsen , as is often the case with idiopathic epilepsy.There is a predominance of personality changes characteristic of alcohol degradation, and not for the epileptic process.

The diagnosis is made taking into account the history and clinical manifestations. Indications of prolonged use of alcoholic beverages, the absence of seizures prior to the onset of alcohol dependence, and the relationship between seizures and refusal to drink alcohol are of diagnostic value. The data of additional studies are of little informative, epileptic signs on the electroencephalogram are usually absent.

Treatment and prognosis for alcoholic epilepsy

Patients with status epilepticus and multiple seizures are admitted to the intensive care unit to maintain vital body functions. Transfusions of glucose and saline solutions are carried out, diazepam, hexobarbital and thiopental are administered. The rest of the patients are referred for examination and treatment to the narcological department. Anticonvulsants (usually carbamazepine) are used. Phenobarbital is rarely used, since this drug is contraindicated in alcoholism.An exception is seizures that are resistant to the action of other anticonvulsants. If there are sufficient indications, phenobarbital is prescribed only in a hospital setting, under constant monitoring of the patient’s condition.

A prerequisite for the successful treatment of this pathology is the complete cessation of alcohol intake. The tactics of treating alcohol dependence are determined by a narcologist. Individual and group psychotherapy, hypnosuggative techniques, drug coding using implants and intravenous drugs can be used.If necessary, the patient is referred to a specialized rehabilitation clinic.

With a complete rejection of alcohol, the prognosis is favorable. In most cases, the seizures disappear completely. Personality changes characteristic of epilepsy are not observed, the severity of mental disorders and personality disorders is determined by the duration and severity of alcoholism. With continued use of alcohol, an increase in the frequency of attacks is possible. The patient’s life can be threatened with the development of status epilepticus and alcoholic psychosis, as well as with injuries due to generalized convulsive seizures.

90,000 Questions and answers for people with epilepsy and their families

1. Are people with epilepsy at higher risk of contracting COVID-19?

There is currently no evidence that people with epilepsy have a higher risk of infection than the general population.

People with controlled seizures while taking medications, as well as those with seizures, but no comorbidities, are not at increased risk.

In some people, epilepsy is part of a syndrome or is associated with other diseases.In such cases, epilepsy is combined with other health-related problems. If they affect the state of the immune system, then the risk of infection increases. At high risk are people with weakened immunity, the elderly, and people with chronic diseases such as diabetes mellitus, cancer, hypertension, heart disease and chronic lung disease.

Persons with uncontrolled seizures, in particular those caused by hyperthermia or infection, are at risk of increased seizures when infected, but there is currently no evidence of this.For people with epilepsy, in this situation, it is extremely important to constantly take medications and avoid factors that provoke seizures (alcohol intake, sleep deprivation, etc.).

2. Do people with epilepsy have a higher risk of complications from COVID-19?

Individuals with weakened immune systems or chronic illnesses are at higher risk of complications. The Centers for Disease Control and Prevention (CDC) in the United States has listed epilepsy as a condition that can increase the risk of severe COVID-19, likely because it is a chronic neurological disease.The UK has included people with chronic neurological disease (no indication of epilepsy) at risk.

3. Do any anticonvulsants increase the risk of contracting COVID-19 or complications of COVID-19 infection?

No. There is no evidence that taking antiseizure drugs increases the risk of infection or serious complications.

4. Can seizures get worse or more frequent when infected with COVID-19?

At the moment, it is known that when infected with COVID-19, the risk of seizures in most people with epilepsy is low.In general, with infectious diseases, in particular, with an increase in temperature, attacks may become more frequent. Illness is stressful for the body, and stress also increases the risk of seizures.

5. What if I think I have COVID-19?

If you think you may have COVID-19, call your doctor or the Coronavirus Hotline.

The most common symptoms of COVID-19 are fever and dry cough.Most people are mildly ill and can be treated at home. If you do not live alone, try to stay as far away from others as possible. Everyone living with you must stay at home for two weeks (14 days) to avoid spreading the virus to other people.

If you have any of the following symptoms, see your doctor immediately:

• Shortness of breath
• Constant pain or pressure in the chest
• Blue lips or face

6.How can I get anticonvulsants if they are running low?

You should be able to get a new prescription in the usual way – whether from the doctor of the polyclinic or in the hospital. Your doctor may be writing a prescription for a longer time than usual. There is currently no evidence that anticonvulsants are in short supply.

7. Should I go to the emergency room if I have a seizure or a series of seizures?

Emergency departments may be overcrowded due to COVID-19, or people with symptoms of COVID-19 may be expected.Patient flows with and without COVID-19 symptoms are divided in many hospitals. However, if possible, try to avoid hospital visits. If your situation is not life-threatening, but you think you need to see a doctor, it is best to call him first.

You should have a clear idea of ​​when and where you should contact, if necessary. Patients with medication to take in an emergency should be well aware of when to use the medication and when to seek emergency care.

Most tonic-clonic seizures (seizures with seizure activity) last less than 2-3 minutes and do not require emergency medical attention or hospital treatment.

Medical / inpatient care is required in case of:

• if tonic-clonic seizures last more than 5 minutes or if a series of seizures occurs and there is no access to emergency medications,
• if convulsions occur in water (bathing, swimming),
• if seizures are followed by prolonged post-ictal symptoms (eg, confusion after seizure) or recovery from seizure is not proceeding as usual,
• if the attacks are potentially traumatic.

8. I am participating in a clinical trial and taking an experimental drug. What should I do?

You should continue taking medications, despite the fact that the study control and doctor’s consultations can be carried out by telephone or video link, and a blood test, if necessary, will be taken at the local clinic. The hospital responsible for your monitoring should inform you of this. In addition, it is likely that they will arrange for the delivery of medications for you when a re-appointment is required.If you are admitted to hospital for any reason, make sure the hospital knows you are taking an experimental drug.

9. I have read several warnings that some antipyretic drugs are not safe to take if I am infected with COVID-19. This is true?

Ibuprofen, naproxen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain and fever; they also reduce inflammation. Paracetamol (acetaminophen) relieves pain and fever, but does not affect inflammation.Despite the existing fears that the use of NSAIDs aggravates the course of the disease, there is no convincing evidence to support this.

If you have a high fever or body aches, you can take one of these medicines to relieve your condition, but follow the instructions exactly.

10. Is there any risk for people with epilepsy when wearing masks?

There are no contraindications for wearing masks for people with epilepsy.

The US Centers for Disease Control and Prevention recommends not wearing cloth masks for children under two years of age, as well as for persons with breathing difficulties, those who are unconscious, are bedridden, and in cases where it is not possible to remove the mask without outside help.

In the event of a convulsive seizure, it is recommended that someone else carefully remove the mask from the victim to ensure optimal airway patency.

11. Does the emergency use of buccal or nasal medicines entail any risks?

Buccal or intranasal midazolam is used when the attack lasts more than 5 minutes; it is also possible to use the drug in the form of a spray. The recommendations for the use of nebulizers state that there are no risks in this case, since the aerosol generated by the device is formed in the nebulizer chamber. The lack of risks also applies to midazolam used in buccal or intranasal form.

When outside the home, for safety reasons, it is recommended that the person taking the medication wear a mask, gloves and protective apron . Remember to also wash your hands after taking the medicine.

* Aerosol-Generating Procedures and Patients with Suspected or Confirmed COVID-19

12. I have heard that people with respiratory problems associated with COVID-19 are advised to lie on their stomach to improve air circulation in the lungs.What is recommended for people with epilepsy and a comorbid COVID-19 diagnosis?

Recent data indicate improved breathing in people with COVID-19 lying on their stomach. However, sleeping in this position has been associated with Sudden Death Syndrome in Epilepsy (Sudden Death Syndrome).

People with epilepsy and severe respiratory distress due to COVID-19 should be hospitalized. The hospital staff will advise on the best sleeping position and provide 24/7 surveillance.If the patient is at home and has respiratory problems associated with COVID-19, it is necessary to see a doctor.

13. What if I have questions that were not covered?

Call your doctor or the COVID-19 Hotline. The appointment at many clinics has been replaced by telephone or video consultations, so your doctor or one of his colleagues can still answer your questions by telephone.
You can also get more information from the links below.

Epilepsy Foundation of America

American Academy of Neurology

UK Epilepsy Society

World Health Organization）

More useful links for patients with epilepsy

90,000 Epilepsy treatment in Israel: prices, reviews, methods 2020

Epilepsy is one of the most common diseases of the nervous system, which is manifested by recurrent seizures.They can be accompanied by screams, falls, cramps, foaming at the mouth, and hoarse breathing. If you suspect or have this disease, you should consult a qualified doctor as soon as possible.

MDC International will diagnose and draw up a treatment plan for epilepsy in Israel. We will take care of all organizational issues related to choosing a clinic and a doctor, buying tickets, escorting, etc.

You can find out the prices of procedures in a special section on the website.The final price will be known after the diagnosis.

Consultation

From 590

EEG at rest and in sleep

From 270

• • Cashless payments
• • Cash payment
• • Payment is made in dollars and euros.

Accepted payment methods: cash, through terminals, any bank cards and bank transfers.

The primary signs of epilepsy in adults include:

• • Visual and auditory hallucinations.
• • Feelings of bliss or fear.
• • Rapid heartbeat, nausea.
• • Senseless pronunciation of words.
• • Motor automatism.
• • Cold, numbness.

The following forms of the disease are distinguished:

• • Local.
• • Generalized (cryptogenic, symptomatic or idiopathic).
• • Alcoholic.
• • Night.
• • Genetic.

Treatment of cryptogenic focal epilepsy in Israel can be very successful, but only with timely contact with MDC International. This is a fairly severe form of chronic disease.

The presence of this disease increases the risk of head injuries, fractures, bruises, which can be obtained during an attack or with a sharp fall due to seizures. There is a possibility of getting into an accident, falling from a height, getting domestic and industrial injuries, drowning.Centers for the diagnosis and treatment of epilepsy in Israel will help to avoid these and many other serious consequences and complications.

People with epilepsy face the following problems:

• • Loss of legal capacity.
• • Deterioration of intelligence and mood, behavioral problems.
• • Increased mortality.
• • Risk of having children with disabilities.
• • Restrictions on sports (swimming, skating, gymnastics, mountaineering, basketball, horse riding, running, cycling).

It is not at all necessary to deprive yourself of a fulfilling life. It is enough to undergo epilepsy treatment in Israeli clinics. MDC International will select the best medical center for you, taking into account the form of your disease and will accompany you at all stages.

In 75% of cases, epilepsy first appears in childhood or adolescence. The nervous system of children differs from that of an adult, therefore, the course of the disease has a number of features.

The MDC International clinic in Israel pays increased attention to the diagnosis and treatment of childhood epilepsy.Despite the fact that small patients are characterized by favorable symptoms that disappear without a trace as they grow older, in some cases epileptic encephalopathies are revealed, which can negatively affect the development of the child. It is very important to recognize malignant syndromes in time, since without treatment, harm to the body will persist, even if the seizures disappear.

Often parents are faced with childhood epilepsy without knowing it. Israeli experts note that at least 5% of children suffered from febrile seizures with fever.Febrile seizures are not dangerous on their own, but if each ARVI is accompanied by seizures, this is a reason to see a doctor.

MDC International multidisciplinary clinic in Israel specializes in the early detection of epilepsy. Modern diagnostic equipment helps to study in detail the case of each patient.

The diagnosis of epilepsy in Israel is divided into two important stages:

1. Primary. For patients who have not yet been diagnosed. Includes EEG, MRI, CT.
2. Additional. Essential for those who are already being treated for epilepsy. Experienced Israeli doctors will carry out genetic tests, check the blood and determine the concentration of medications taken in it.

Electroencephalography

Data from different parts of the brain are recorded and studied. The result is analyzed by a special computer program and the attending physician. If during the study the patient has seizures or pathological patterns, this will be seen in the decoding.

Modern equipment at the MDC International clinic allows the use of several EEG methods for the diagnosis of epilepsy:

1. Video monitoring. The study lasts from 1 to 12 hours. If the results are controversial, the recording time can be extended. During the procedure, a specialist observes the patient, which allows identifying the slightest deviations.
2. Routine EEG. 15 minute recording of brain activity. The starting point for disease detection.

General and biochemical blood tests

At the MDC International clinic, all patients are prescribed a complete blood count with platelets and leukocyte count.This is necessary to identify side effects from previous treatment. Additionally, we will check total protein, AST, creatinine, ALT, alkaline phosphatase, sodium, urea, potassium, amylase and calcium.

Determination of the concentration of drugs in the blood

The content of drugs in the blood is monitored during treatment. If the medications do not work, the search for the causes and the adjustment of the treatment plan begins.

MRI and CT

Neuroimaging methods that are used to obtain images of the structures of the nervous system.In order to examine the bones and blood vessels, CT is used, for loose structures, for example, the parenchyma of the brain – MRI. With the help of tomography, the doctor identifies the cause of the disease, which allows him to develop an effective treatment plan.

For MRI diagnostics of epilepsy in Israel, children under three years of age are given general anesthesia, since during the study you need to lie still. We use the latest drugs with minimal side effects, the doctor monitors the child’s condition throughout the study.

Genetic research

Diagnosis of epilepsy in Israel includes checking for gene and chromosome abnormalities. The karyotype is examined, tandem mass spectrometry is carried out, some genetic diseases are excluded using the “gene panel”. Treatment of hereditary epilepsy differs from classical methods, therefore Israeli doctors recommend genetic testing for all patients.

Many types of epileptic seizures can be controlled by medication and diet therapy.If there is no positive dynamics, they resort to surgical operations. When choosing a method for treating epilepsy in adults, the doctor takes into account:

• • Frequency of seizures.
• • The degree of their severity.
• • Health status.
• • Age.

Drug treatment

Medicines with proven efficacy and minimal side effects are used. An individual regimen is prescribed, the content of drugs in the blood is monitored.

Callosotomy

If the patient does not respond to drugs, electrical stimulation of the brain is performed through the vagus nerve. This will not completely remove the attacks, but will reduce their number and intensity, which will improve the patient’s quality of life. The procedure is minimally invasive. An electrical stimulator inserted into the armpit sends impulses to the brain to prevent seizures. After 5-10 years, the stimulant will need to be replaced.

Partial lobectomy

Completely eliminates attacks of temporal lobe epilepsy.Israeli surgeons remove the amygdala, the anterior temporal lobe, and the hippocampus. Due to the complexity of the operation, such an intervention is possible only for adult patients. The manipulations are carried out through a small hole.

Hemispherectomy and cortical resection

Both methods are used only if other methods of treating epilepsy do not help. Israeli specialists will remove fragments of the cerebral cortex or one of the anterior temporal lobes. Hemispherectomy is performed for adults and children. Before starting to plan the operation, the doctor will determine the location of the focus of the disease, visualize it in a special program.

In the treatment of childhood epilepsy in Israel, a sparing complex therapy is used. Before we start treating a child, we will identify the frequency of seizures and the presence of communication, mental and cognitive impairments. If the seizures are benign, only monitoring of the patient’s condition will be required.

To begin with, we recommend changing your lifestyle: sleep longer, move a lot. Often, attacks go away when drugs are canceled: antihistamines, local anesthetics, neuroleptics, Indomethacin, Theophylline, Interferon.Doctors of MDC International will draw up an individual vaccination schedule for a child with epilepsy, and in case of concomitant chronic diseases, they will replace the drugs that provoke seizures.

If this is not enough, we turn to medication. The selection of drugs and the scheme of their use are individual. Traditionally, therapy is started with the following drugs: Carbamazepine or Valproic acid. If there is no improvement, a second drug is administered. Classic medicines can be replaced with new generation products.

As a last resort, when treating pediatric epilepsy, we resort to an operation performed by a team of the best pediatric surgeons in Israel.

To receive an effective treatment for epilepsy in Israel, fill out a short application. Enter your name, email, phone number, and describe your problem. Then:

1. An MDC International representative will contact you within 24 hours.
2. We will diagnose and select one of the best clinics in Israel for the treatment of epilepsy.
3. We organize the move, taking on the purchase of tickets, booking a date, accommodation.
4. We will provide full support: we will order a transfer, we will deal with the translation of medical documents, we will solve all everyday issues.

A properly formed antiepileptic program will help to completely get rid of seizures or reduce their frequency in severe cases.

You can consult on the treatment of epilepsy in Israel by phone +7 (495) 127-01-43.or using .

Reviews of the work of the clinic’s doctors can be found on the website.

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