This is an interesting book, directed at a wide audience including neurologists, medical students, social workers, and pharmacists, which sets out to demonstrate the management of epilepsy in practice by presenting case histories of people with seizures. The issues addressed include such common clinical difficulties as diagnosis (and the problem of non-epileptic attacks), epilepsy in pregnancy, withdrawal of antiepileptic drugs, and status epilepticus. Alternative therapies and psychiatric issues are also discussed. Each history is followed by questions about the management of the patient, which the author answers according to his practice, with appropriate explanations. The second part of the book consists of a sizeableResources section providing such diverse information as the classifications of epileptic seizures and syndromes, seizure history checklist, home safety checklists, lists of drugs and their modes of action, websites for physicians and patients, lists of epilepsy centres, and driving regulations within the United States.
Both sections of the book contain a wealth of information, and the histories, which are easy to read, provide a useful insight into the problem areas of epilepsy, together with possible solutions. Inevitably the views given describe the author's personal practice, and the nature of the book does not allow detailed examination of the evidence underlying the decision making. However, it emphasises the importance of tailoring treatment to the individual patient, and addresses the social issues in a manner often missing from larger texts. I found the fact that the book was clearly directed at an American audience, which was apparent not only in the Resourcessection, but also colouring the choice of medication and the advice given (for example, on driving), somewhat distracting. Nevertheless, it should prove useful reading for those involved in the care of people with epilepsy.
by Alan Batt. Last modified: 15/03/14
Patient & Apparent Chief Complaint
A 65 year old female presents to ambulance crew after call from her husband stating patient having possible CVA. Upon arrival patient is found to be having a tonic-clonic seizure.
Patient could not verbalise to husband when he woke up. He tried to talk to her, and stated she was making an effort to talk back to him but could not make sounds. The patient was lying in actively seizing upon arrival of ambulance crew.
Initial Clinical Findings
- Airway – unobstructed
- C Spine – not suspected, no MOI
- Breathing – regular
- Circulation – Pulse present, irregular; skin colour flushed, cap refill normal (>2 sec)
- Disability – LOC before ambulance arrival; patient unable to talk, actively seizing
- A – No known allergies
- M – Currently taking Epanutin (anti-convulsant), Aspirin, Rouvastatin and Eltroxin
- P – History of TIAs, numerous previous seizure episodes resulting in hospitalisation (? epileptic in nature), hypercholesterolaemia
- L – Dinner 8pm the evening previous
- E – Husband stated patient had eyes open upon waking but unable to verbalise
- Pulse rate 134bpm
- Pulse rhythm Irregular
- ECG rate 126
- ECG rhythm A Fib, unifocal PVCs
- Resp rate 12 per minute, normal, regular
- Resp quality Equal air entry bilaterally
- SpO2% 99% on 100% O2 via NRB
- Cap Refill <2secs
- BP 176/68
- Pupils PEARRL, size 6
- GCS 7/15 (E4, V2, M1)
- BGL 9.0mmol/l
Pre-hospital care & management
O2 @15lpm commenced via non-rebreather mask. Diazepam 5mg PR administered as patient actively seizing. Transferred to ambulance, further 5mg of Diazepam PR was administered. 12 lead ECG obtained during post-ictal phase. IV access gained in right dorsum. GCS reduced to 3/15, patient unresponsive. NPA (Size 6mm) inserted into left nostril, tolerated. En-route to hospital patient had 6 further tonic-clonic seizures – 5mg Diazepam PR & 5mg Diazepam IV administered, seizures resolved. Suction provided as snoring respirations evident, large amounts of saliva building up in mouth. Ventilations assisted as RR<10 per minute. Resuscitation equipment prepared as patient having runs of Ventricular Tachycardia. Total 15mg Diazepam PR and 5mg Diazepam IV administered pre-hospital.
In-hospital care & management
Triaged as Category 1 (Life-Threatening Condition) with Unconscious, Seizures, ? CVA. Brought directly to Resus room. Aggressive airway management commenced. Lorazepam 5mg IV administered. Patient RSI’d to secure airway. Urinary catheter inserted. Sent for CT Brain. No intra-cerebral haemorrhage found on CT scan. Patient sent to ICU on ventilator, remained sedated. Poor prognosis, same discussed with family by medical team.
Identification of all interventions initiated and rationale
- Pulse oximetry – to monitor oxygen saturation levels in the blood
- Vital signs (HR, RR, SpO2, BM) – to gain a baseline set of vital signs for reference
- Diazepam – anticonvulsant medication, to stop seizure activity
- Nasopharyngeal airway – to protect the airway due to decreased level of consciousness
- Suction – to clear the airway of saliva due to patient’s inability to maintain own airway
- Pulse oximetry – to monitor oxygen saturation levels in the blood
- Supplemental oxygen – to re-oxygenate patient
- Assisted ventilations – to provide adequate oxygenation to patient’s tissues as RR <10
- 3 Lead ECG – to identify any life-threatening arrhythmias
- 12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes indicative of myocardial damage (secondary to hypoxia etc.)
- IV access – to allow for IV medications to be administered
- CXR – to identify aspiration, pleural effusion etc. that may increase morbidity
- Blood tests – to identify any electrolyte imbalances etc.
- Urinary catheter – to monitor urinary output to ensure adequate renal function
- CT Brain – to identify any cerebral haemorrhage or infarct that may be indicative of cause of altered LOC/seizures
Initial therapy choice in treatment of seizures
Benzodiazepines are the agents of first choice in management of seziures (Dionisio, 2013). Both diazepam and lorazepam are members of the benzodiazepine group of medications.
The ability of Paramedics of all grades to control patients who are actively seizing is an area that needs attention in some systems. Paramedics being able to provide midazolam and/or diazepam through various additional routes such as intranasal, per rectum, buccal or intramuscular would result in improved outcomes for patients.
- A 2008 review by Appleton et al. found that intravenous lorazepam is at least as effective as intravenous diazepam and is associated with fewer adverse events.
- IM administration of lorazepam is more reliable and is the recommended medication to be given IM if required (Munne, 1990)
- Prasad et al. (2005) stated that in patients experiencing status epilepticus, lorazepam is better than diazepam for cessation of seizures, and has a longer duration of effect and should be the first therapy of choice for patients experiencing status epilepticus.
- Lorazepam has a much longer duration of anti-convulsant action than diazepam and has an equivalent onset of action (Cock & Schapira, 2002)
- Some caregivers and parents are already trained in the administration of PR diazepam.
- Diazepam administered per rectum is shown to be as effective as diazepam given intravenously (Lahat et al., 2000), although bioavailability varies considerably from patient to patient.
- Per rectum administration is also shown to have a lesser respiratory depressive effect than IV administration.
- IM administration of diazepam is erratic and may be significantly delayed.
- Rainbow et al. (2002) found that intranasal midazolam can control seizures as effectively as diazepam in the prehospital setting.
- Intranasal midazolam can also result in a comparable time to cessation of seizures to that of intravenous diazepam (Lahat et al., 2000)
- Wolfe & Macfarlane (2006) found that intranasal midazolam can provide better seizure control than PR diazepam, and is easier for paramedics to administer to a patient who is actively seizing.
- A number of authors (Scott et al, 1999; Queally, 2007; Wilson et al., 2004; Humphries & Eiland, 2013) also found that patients and caregivers found intranasal midazolam to be more socially acceptable than per rectum administration of diazepam, as well as re-confirming the view it was more convenient for paramedics to access the intranasal route than the per rectum route.
- Queally (2007) concluded that buccal midazolam may be useful in the community setting in the treatment of prolonged and serial seizures and the prevention of status epilepticus.
- Chamberlain et al. (1997) concluded that IM midazolam is an effective anticonvulsant for children with seizures and an important alternative when IV access is not available.
- Where intravenous access is unavailable there is evidence from one trial that buccal midazolam is the treatment of choice (Appleton et al., 2008)
PHECC CPGs state Diazepam 5mg IV (repeat to a max of 10mg) as the first choice therapy for actively seizing patients. The JRCALC guidelines (2006) also recommend Diazepam 5mg IV (repeated to a max of 10mg) as the first choice therapy for seizure management.
The provision of buccal and/or intranasal midazolam to all Paramedics is therefore a recommendation, and would result in the ability of Paramedics to provide patients who are actively seizing with an immediate, safer resolution to their seizure state.
Status epilepticus is usually defined as 30 minutes of uninterrupted seizure activity. However, varying definitions exist, ranging from 5-30 minutes in duration. Another definition is “an epileptic seizure that is sufficiently prolonged or repeated at a significantly brief interval so as to produce an invarying and enduring epileptic condition” (Gastaut, 1973) Status epilepticus is associated with significant morbidity and mortality.
Mortality associated with status epilepticus has been reported at between 18% and 23% (Logroscino et al., 1997) The ability of Paramedics to intervene in cases of status epilepticus with appropriate pharmacological interventions, thus reducing the mortality associated with it is an important aspect of prehospital care.
Seizures in patients presenting with CVAs
CVAs account for approximately 10-55% of symptomatic seizures in the 55-plus age group, and in a number of studies accounting for a larger percentage as age increases (Annergers etc al., 1995; Cossu et al., 2012; Tchalla et al., 2011). A number of studies have shown that post-ischaemia seizures (i.e. post-CVA seizures) are associated with an increased mortality rate (Arboix et al., 2003)
Results regarding the impact of ischaemia induced post-CVA seizures on mortality outcome are however, inconsistent at best. According to Camilo & Goldstein (2004) experimental studies to date suggest that seizure-like activity in the presence of cerebral ischemia can significantly increase the size of cerebral infarct and can impair long-term recovery.
Airway management in the actively seizing patient
The management of the airway in the actively seizing patient is the priority of care and is paramount to a successful patient outcome. Basic manoeuvres, a nasopharyngeal airway and suction of secretions in the oral cavity if required are the basic tenets to successful airway management in the seizing patient (Graham & Gordon, 2001; AAOS, 2005; Elling et al., 2007). It is important for practitioners to remember that basic management of the airway can be as successful, if not more than advanced management in the actively seizing patient.
AAOS (2005) Emergency Care and Transportation of the Sick and Injured 9th Edition. Massachusetts: Jones & Bartlett
Elling B, Caroline N, Smith M (2007) Nancy Caroline’s Emergency Care in the Streets, 6th Edition (UK Edition). London: LWW
Munne P (1990) Diazepam: International Programme on Chemical Safety – Poisons Information Monograph 181. [http://www.inchem.org/documents/pims/pharm/pim181.htm] Accessed 10th November 2013.
Queally C (2007) The use of buccal midazolam in emergency seizure management in epilepsy British Journal of Neuroscience Nursing (3) 6; 272-275
Humphries LK1, Eiland LS. Treatment of acute seizures: is intranasal midazolam a viable option? J Pediatr Pharmacol Ther. 2013 Apr;18(2):79-87. PMID: 23798902.
Seizures in the pediatric population commonly occur, and when proper rescue medication is not administered quickly, the risk of neurologic compromise emerges. For many years, rectal diazepam has been the standard of care, but recent interest in a more cost-effective, safe alternative has led to the […]
Prasad K1, Krishnan PR, Al-Roomi K, Sequeira R. Anticonvulsant therapy for status epilepticus. Br J Clin Pharmacol. 2007 Jun;63(6):640-7. PMID: 17439538.
To determine whether a particular anticonvulsant is more effective or safer than another or placebo in patients with status epilepticus, and to summarize the available evidence from randomized controlled trials, and to highlight areas for future research in status epilepticus. […]
Logroscino G1, Hesdorffer DC, Cascino G, Annegers JF, Hauser WA. Short-term mortality after a first episode of status epilepticus. Epilepsia. 1997 Dec;38(12):1344-9. PMID: 9578531.
Studies evaluating short-term mortality among people who experience status epilepticus (SE) have produced conflicting results. Most studies are derived from clinical series with results affected by unspecified follow-up period and select referral of cases. This study was planned to evaluate short-te […]
Gottwald MD1, Akers LC, Liu PK, Orsulak PJ, Corry MD, Bacchetti P, Fields SM, Lowenstein DH, Alldredge BK. Prehospital stability of diazepam and lorazepam. Am J Emerg Med. 1999 Jul;17(4):333-7. PMID: 10452426.
Injectable benzodiazepines are commonly stocked on ambulances for use by paramedics. We evaluated the stability of lorazepam and diazepam as a function of storage temperature. Diazepam (5 mg/mL) and lorazepam (2 mg/mL) injectable solutions were stored for up to 210 days in clear glass syringes at th […]
Camilo O1, Goldstein LB. Seizures and epilepsy after ischemic stroke. Stroke. 2004 Jul;35(7):1769-75. PMID: 15166395.
Although a long-recognized clinical phenomenon, there remain many questions regarding the epidemiology of seizures and epilepsy after ischemic stroke, their effect on outcome, and their treatment. […]
Arboix A1, Comes E, García-Eroles L, Massons JB, Oliveres M, Balcells M. Prognostic value of very early seizures for in-hospital mortality in atherothrombotic infarction. Eur Neurol. 2003;50(2):78-84. PMID: 12944711.
We studied the influence of very early seizures (within 48 h of stroke onset) on in-hospital mortality in a cohort of 452 consecutive patients with atherothrombotic infarction. These patients were selected from 2000 consecutive acute stroke patients registered in a prospective hospital-based stroke […]
Annegers JF1, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia. 1995 Apr;36(4):327-33. PMID: 7607110.
We determined the incidence of seizures due to acute CNS insults for residents of Rochester, Minnesota, U.S.A., from 1935 through 1984. The age-adjusted incidence rates for 1955-1984, the period of most complete case ascertainment, was 39.0/100,000 person-years (United States 1970 population as stan […]
Cossu P1, Deriu MG, Casetta I, Leoni S, Daltveit AK, Riise T, Rosati G, Pugliatti M. Epilepsy in Sardinia, insular Italy: a population-based prevalence study. Neuroepidemiology. 2012;39(1):19-26. PMID: 22777403.
Sardinia, insular Italy, represents a particular epidemiological setting to investigate polyfactorial diseases, by virtue of its phylogeny and geographic isolation over time and of a well-established network of health operators and information systems. We present the first prevalence study of epilep […]
Tags: case study, clinical management, neurology, seizure