Emergencies in general practice: Seizures and status epilepticus
Witnessing a seizure in the surgery or in a public place can be an unnerving experience, but knowing how to respond can help prevent a 'fit' progressing into life-threatening status epilepticus. In this article, we will discuss immediate management of the patient presenting with a seizure or in status epilepticus, and provide an overview of diagnosis, management and the current approach to treatment of epilepsy
Wendy is the cleaner at the surgery. She comes into work at lunchtime and seems to be a bit quiet and vague — not her usually chatty self. After about ten minutes you hear a long, loud cry and then a shout for help from reception. Wendy is having a seizure in the middle of the reception area. A quick assessment of the situation reveals a medical bracelet on Wendy's wrist stating that she suffers from epilepsy.
BACKGROUND
Approximately one in ten of the UK population suffers from epilepsy. Epilepsy is the result of abnormal, irregular bursts of electrical activity in the brain and the most common symptom of epilepsy is the presence of seizures. However, there are different types of epilepsy which can present in different ways depending on which area of the brain is affected by the abnormal electrical activity. The most obvious type of seizure is the tonic-clonic type, which if not controlled, can develop into status epilepticus (SE).
Status epilepticus is a potentially life threatening condition where the sufferer has a prolonged seizure or several seizures which occur one after the other with little or no opportunity for recovery in between. Other types of seizures may be seen other than those that are epileptic in nature — these include febrile convulsions and those associated with hypoglycaemia or alcohol withdrawal. Some people can have a single convulsion in their lifetime for no obvious reason and without going on to develop epilepsy, and the diagnosis of epilepsy will usually only be made on the basis of recurrent (at least two) seizures.
DIAGNOSIS OF EPILEPSY
The diagnosis of epilepsy is based on the history of the seizures as this will help to differentiate one type of epilepsy from another. An electroencephalograph (EEG) and magnetic resonance imaging (MRI) scan may then be performed to identify any abnormal electrical activity within the brain and to aid diagnosis and classification.
Some epilepsies occur as part of a syndrome of other symptoms and this may affect ongoing management so correct diagnosis is essential. The International League Against Epilepsy (ILAE) has compiled a classification list of the types of seizure that may be seen.1
In the first instance, seizures are identified as being focal or generalised seizures and this description relates to where in the brain the abnormal electrical activity is happening and how this affects the body. Focal seizures happen as a result of abnormal activity in one hemisphere of the brain and often in a specific lobe, the temporal and frontal lobes being common sites. The effects of a focal seizure can be relatively mild and may include twitching or experiencing odd sensations such as visual, taste or sound effects that are not actually there. Frontal lobe epilepsy can result in behavioural changes which may be confused with other conditions. Epilepsy Action's website has detailed information about the types of focal seizures that may occur.2 Occasionally, focal seizures may go on to become generalised ones. Generalised seizures involve both sides of the brain and include tonic-clonic seizures where the individual will shake, lose consciousness and fall down.3
TONIC-CLONIC SEIZURES
Tonic-clonic seizures involve intermittent spasm and relaxation of the muscles causing the typical appearance of a convulsion. These movements may also be associated with loss of bladder and/or bowel control, and may also involve disruption to the breathing, which may lead to central cyanosis. All of this can be very alarming to onlookers but there are some simple rules which should be observed:
1. Keep the patient safe and remove any potentially harmful objects around them such as furniture and spectacles
2. Do not restrain them in any way or place anything in the mouth; once the seizure has ended, the patient can be put into the recovery position to maintain the airway
3. Make a note of the time, if possible, to monitor the length of the seizure
4. Maintain a quiet and non-threatening environment as this can be a very frightening and disorientating experience for the patient, even if they have had seizures before
5. Stay with the patient until they have recovered or the ambulance has arrived
Not everyone who has a seizure will need admission to hospital. Indications for possible admission include if it is a first convulsion and the cause is unknown, if the seizure has lasted more than 5 minutes or if the person has sustained an injury which requires hospital assessment.
STATUS EPILEPTICUS
The actual definition of SE has been the subject of much discussion over the past few decades but NICE defines it as a generalised convulsion which last 30 minutes or more, or where repeated tonic-clonic convulsions occur over a 30 minutes period without recovery of consciousness between each convulsion.4 In children a convulsion lasting 5 minutes or more is considered to be an indication to start the SE treatment protocol with a view to stopping the seizure as quickly as possible and reducing the risk of SE.
NICE has produced guidelines for managing SE in adults and children and a summary of these can be downloaded from its website. 4 These guidelines cover the overall management of SE from presentation to specialist intensive care. For primary care, the recommendations are shown in Box 1.
Following arrival in hospital, intravenous benzodiazepines and anti-epileptic drugs (AEDs) may then be given.
TREATMENT OF EPILEPSY
There is no real cure for epilepsy, although some surgical treatments are available in severe and specific cases. In most people treatment will be based around stopping the seizures through the use of AEDs. AEDs are effective in the majority of people and will successfully eradicate, or at least reduce, the number of seizures. However, it takes time to find the right combination of drugs to do this as this will be individual to each person.
SUDDEN UNEXPECTED DEATH IN EPILEPSY
Sudden unexpected death in epilepsy (SUDEP) is a rare but devastating complication of epilepsy. It has been estimated that between 500 and 1,000 people each year die as a result of SUDEP. It is important that people with epilepsy and their families understand the importance of continuing to take medication, even when they are well, to prevent seizures and reduce possible risks. Avoidance of triggers is also important, and it is important that everyone with epilepsy is reminded of the particular importance of a healthy lifestyle. Missing meals, tiredness, stress and excessive alcohol intake are all known to trigger seizures in people with epilepsy and young adults may be at particular risk of living more chaotic lifestyles that include some or all of these elements. It is important, then, that sufferers and their families should be reminded about the importance of these factors in avoiding seizures and reducing the risk of SUDEP.
ANNUAL REVIEW IN PRIMARY CARE
Every patient should have an annual review with their specialist and/or GP. Consideration should be given to frequency of seizures, medication and lifestyle, including driving and employment advice. Psychosocial issues should also be discussed with the patient and/or carers. Women of child-bearing age should be advised about managing their epilepsy in the case of pregnancy. Contraception should also be discussed. In patients who have been seizure free for 2 years consideration should be given to reducing or stopping medication with appropriate support from a specialist.
CONCLUSION
In Wendy's case swift assessment and management of the situation meant that she had an uneventful recovery after a few minutes and there was no need for admission. In people who suffer a seizure, the risk of status epilepticus should be borne in mind and initial management will include basic life support and decisions regarding the need for admission. Ongoing care is essential and will include optimisation of medication along with lifestyle advice; advice on employment and driving should be part of the annual review. With all of this, most people with epilepsy will be able to live full and symptom free lives.
REFERENCES
1) International League Against Epilepsy (2011) New concepts in the classification of the epilepsies Epilepsia, 52(6):1058—1062 Available at http://www.ilae.org/Visitors/Centre/ctf/documents/NewConcepts-Classification_2011_000.pdf Accessed June 2013
2) Epilepsy Action (2013) Focal (partial) seizures Available at http://www.epilepsy.org.uk/info/seizures/focal-partial Accessed June 2013
3) Epilepsy Action (2013) Generalised seizures Available at http://www.epilepsy.org.uk/info/seizures/generalised Accessed June 2013
4) NICE (2012) The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care Available at http://publications.nice.org.uk/the-epilepsies-the-diagnosis-and-management-of-the-epilepsies-in-adults-and-children-in-primary-and-cg137/appendix-f-protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-adults#treating-convulsive-status-epilepticus-in-adults-published-in-2004 Accessed June 2013
5) NICE (2012) Treatment algorithm based on seizure type Available at http://guidance.nice.org.uk/CG137/InformationResourcesAndTemplates/PharmacologicalTreatmentBySeizureType/doc/English
6) NICE (2012) Treatment algorithm based on syndrome Available from http://guidance.nice.org.uk/CG137/InformationResourcesAndTemplates/PharmacologicalTreatmentByEpilepsySyndrome/doc/English Accessed June 2013
