1. Assess ABCs. If an active convulsive seizure occurs during assessment, place patient on side, control airway, and protect from objects that may fall onto or otherwise harm patient during seizure. Do not place any object into patient's mouth during seizure. Status epilepticus is defined as a seizure, or recurrent seizures, lasting more than 30 minutes, during which patient does not regain consciousness. Any type of seizure can progress to status epilepticus. Patients with an established seizure disorder may have been prescribed a rectal benzodiazepine medication that can be given to terminate a seizure.
2. Establish IV access (for medication administration) and obtain appropriate blood tests (see IV, B, earlier).
3. Give patient 50% dextrose solution IV for possible hypo-glycemia.
4. Treat active convulsive seizure with lorazepam, 0.05-0.1 mg/kg IV, over 5 minutes (maximum of 4 mg per dose). Watch for respiratory depression. If IV access is not available, diazepam may be given rectally at a dose of 0.2-0.5 mg/kg, depending on patient's age.
5. If seizure persists, load with fosphenytoin, 20 phenytoin equivalents (PE)/kg IV or IM, over 10 minutes. Fosphenytoin (5-10 PE/kg) can be repeated if seizure persists. If seizure persists after repeated doses of fosphenytoin, load with phenobarbital, 20 mg/kg, over 20 minutes. Watch for respiratory depression. Patients who are already receiving valproic acid can be loaded with valproate sodium IV infusion, 15-25 mg/kg.
6. Patients with seizures that persist despite these interventions may require intubation, mechanical ventilation, and general anesthesia. Agent most often utilized in this setting is pentobar-bital, because response can be titrated, followed by continuous bedside EEG monitoring. Load patient with 15-20 mg/kg IV, over 1-2 hours, and then maintain on continuous IV infusion of 1 mg/kg/h. Infusion is weaned after 1-5 days to assess clinical effectiveness.
B. Seizure Control. Anticonvulsant medications are mainstay of management for seizures. Decision to initiate anticonvulsant medication is based on history and EEG findings. Most patients will not start an anticonvulsant medication until they have had at least two clinical events.
1. Partial seizures. First-line anticonvulsant is carbamazepine; other effective agents include sodium valproate, levetiracetam, and phenytoin.
2. Generalized seizures. First-line anticonvulsant is sodium valproate; other effective agents include levetiracetam and lamotrigine.
3. Absence seizures. First-line agent is ethosuximide; other agents include sodium valproate and lamotrigine.
4. Adverse effects. All anticonvulsant medications have potential adverse effects, and patient and family should be familiarized with these. Routine blood testing can identify some adverse effects, but blood tests are not predictive of impending adverse effects.
C. Follow-up. Patients who take anticonvulsant medications are followed regularly. Typically anticonvulsants are continued for at least 2 seizure-free years.
VI. Problem Case Diagnosis. The 7-year-old boy had spells of inattention that lasted between 5 and 10 seconds, with no other associated activity. Physical exam and prenatal, developmental, and past medical histories were unremarkable. Patient's older sister had similar spells at same age. EEG demonstrated frequent generalized, bilaterally synchronous, 3-Hertz spike-and-slow-wave complexes, lasting 2-10 seconds. Patient was diagnosed with childhood absence epilepsy and was effectively treated with ethosuximide.
VII. Teaching Pearl: Question. What is the typical age of onset for absence seizures, and is it beneficial to initiate treatment early?
VIII. Teaching Pearl: Answer. This disorder typically presents between ages 5 and 9 years (average, 5.7 years). Treatment is not a medical emergency, but early intervention can prevent academic and social difficulties.
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