It is important to distinguish seizures from ‘pseudo-seizures “(p. Ex. Hysteria or tetany) during which there is no true knowledge loss.
– 2 imperatives: stop the seizures and recognize the cause. In pregnant women, seizures in eclampsia context belong to a special care on the medical and obstetrical plan (see page 25).
Initial treatment:
The patient convulses:
– Protect from trauma, ensure the airway, settle in the lateral position, loosen clothing.
– Most seizures yield spontaneously and quickly. The administration of an anticonvulsant is not systematic. If a generalized seizure lasts more than
3 minutes, stop the crisis with diazepam:
Child: 0.5 mg / kg intrarectal1 preferably not exceed 10 mg.
The IV is possible (0.3 mg / kg in 2 to 3 minutes) provided you have the hardware ventilatory assistance at hand (Ambu and mask).
Adult: 10 mg rectally or slow IV
In all cases :
• Dilute 10 mg (2 mL) of diazepam in 8 ml of 5% dextrose or sodium chloride
0.9%.
• If convulsions persist beyond 5 minutes, repeat once the injection.
• For children and elderly, monitor breathing and TA.
• If unsuccessful after the second dose, treat as status epilepticus.
The patient no longer convulse:
– Find the cause seizures and assess the risk of recurrence.
– Keep handy diazepam and 50% glucose if the patient convulserait again.
Status epilepticus:
Series of seizures without full recovery of consciousness between seizures or uninterrupted crisis more than 10 minutes.
– Protect from trauma, loosen clothing.
– Ensure the airway; administer oxygen.
– Insert an IV line.
– Administer 50% glucose IV slowly direct: 1 ml / kg
– If diazepam was administered (as above) without success, continue with
phenobarbital IV slowly in 5% glucose:
Children: 15 mg / kg maximum rate of 30 mg / minute
Adult: 10 to 15 mg / kg at maximum rate of 100 mg / min (maximum dose: 1 g)
When the convulsions stop, reducing the rate of infusion.
There is a very high risk of respiratory depression, which may appear suddenly, especially in young children and elderly patients: closely monitor breathing and have at hand the material to ventilate the patient (Ambu and mask or probe intubation).
Further processing:
– Febrile convulsions
Find the cause of the fever. Give paracetamol (see Fever, page 26), discover, wet wrap.
In children under 3 years old, simple febrile seizures rarely exposed to the risk of further complications and require no treatment after the crisis. In subsequent episodes of fever, paracetamol PO.
– Infectious Causes
Severe malaria (page 131), meningitis (page 165), meningoencephalitis, cerebral toxoplasmosis (pages 217 and 218), cysticercosis (page 153), etc.
– Metabolic Causes
Hypoglycemia: 50% glucose 1 ml / kg by slow IV in any patient who did not regain consciousness and in severe malaria among newborns and malnourished children. Confirmed by a glucose test strip whenever possible.
– Iatrogenic causes
In a patient treated for epilepsy, treatment discontinuation should be organized over a period of 4 to 6 months by gradually reducing the dose. Abrupt withdrawal can cause severe and repeated seizures.
– Epilepsy
• A first brief crisis does not require anti-epileptic treatment. Only chronic conditions characterized by repeated crises justify regular use of anti-seizure treatment, usually for several years.
• Once the diagnosis, no treatment may be recommended because of treatment-related risks but these risks must be balanced with those of drug therapy: risk of worsening epilepsy, brain damage and others traumatic injuries related to seizures.
• Monotherapy is always best first line. The effective dose should be administered gradually and evaluated after a period of 15 to 20 days, on the improvement of symptoms and the patient’s tolerance.
• The abrupt withdrawal can cause status epilepticus.
Dose reduction should be even more progressive than the treatment was long (see iatrogenic causes above).Similarly, a change in treatment should be gradual with an overlap over a few weeks.
• The first-line treatment of convulsive generalized epilepsies are carbamazepine or phenobarbital in children under 2 years and sodium valproate or carbamazepine in children over 2 years and adults. As
indicative:
carbamazepine PO
Child: initial dose of 2 mg / kg / day administered in one or 2 doses; increase each week until the optimal dose for the individual (usually around 10 to 20 mg / kg / day in 2 to 4 doses).
Adult: initial dose of 200 mg / day in one or two taken; increase weekly 200 mg until the optimal dose for the individual (usually around 800 to 1200 mg / day in 2 to 4 doses).
PO valproate
Children over 20 kg: initial dose of 400 mg in 2 divided doses irrespective of weight; gradually increase as needed until the optimal dose for the individual (usually around 20 to 30 mg / kg / day in 2 divided doses).
Adult: initial dose of 600 mg / day in 2 divided doses; increase every 3 days of 200 mg until the optimal dose for the individual (usually around 1 to 2 g / day in 2 divided doses).
PO phenobarbital
Child: initial dose of 3 to 4 mg / kg / day in the evening outlet, gradually increasing to 8 mg / kg / day if necessary
Adult: initial dose of 2 mg / kg / day in the evening taken (not to exceed 100 mg), gradually increasing to 6 mg / kg / day if necessary
Special case: convulsions during pregnancy
– Eclampsia: convulsions in the third trimester of pregnancy, most often in a context of preeclampsia (hypertension, edema, frank proteinuria).
• Symptomatic treatment of eclampsia:
The treatment of choice is the magnesium sulfate by IV infusion: 4 g diluted in sodium chloride 0.9% be administered over 15 minutes. Then infuse 1 g / hour, continue treatment 24 hours after delivery or the last crisis. In case of recurrence of the crisis, administer again 2 g IV slowly (15 minutes).
Monitor urine output. Stop treatment if the urine volume is less than 30 ml / h or 100 ml / 4 hours.
Before injection, verify the concentrations listed on the bulbs: there is a risk of potentially fatal overdose. Always have calcium gluconate to cancel the effect of magnesium sulfate overdose.
Monitor every 15 minutes the knee jerk during the infusion.
If you feel unwell, drowsiness, speech disorders or in case of disappearance of the patellar reflex, stop magnesium sulfate and inject 1 g of calcium gluconate by slow, direct IV (5-10 minutes).
In the absence of magnesium sulfate, use diazepam 10 mg by slow IV relayed by 40 mg in 500 ml of 5% glucose continuous infusion over 24 hours. If no venous access for the loading dose, 20 mg administered rectally and, if unsuccessful after 10 minutes, re-administer 10 mg.
For direct IV or intra-rectal administration dilute diazepam in glucose 5% or sodium chloride 0.9% to complete 10 ml.
• Oxygen: 4 to 6 liters / minute.
• Nursing, hydration.
• Urgent delivery within 12 hours.
• Treatment of hypertension: see Hypertension, page 291.
– Other causes: during pregnancy, think also of seizures associated with cerebral malaria or meningitis, the incidence of which is increased in pregnant women. See page 131 malaria and bacterial meningitis page 165.