Seizures


– Involuntary movements of cerebral origin (stiffness followed by clonic movements), accompanied by a loss of consciousness, and often urinary incontinence (generalized tonicclonic seizures).

– In pregnant women, eclamptic seizures require specific medical and obstetrical care. Refer to the guide Essential obstetric and newborn care, MSF. 

Initial treatment

During a seizure

– Protect from trauma, maintain airway, place patient in ‘recovery position’, loosen clothing.

– Most seizures are quickly self-limited. Immediate administration of an anticonvulsant is not systematic. If generalized seizure lasts more than minutes, use diazepam to stop it: 
diazepam
Children: 0.5 mg/kg preferably rectally1 without exceeding 10 mg
IV administration is possible (0.3 mg/kg over 2 or 3 minutes), only if means of ventilation are available (Ambu bag and mask).
Adults: 10 mg rectally or by slow IV

In all cases:
• If convulsion continues, repeat dose once after 10 minutes.
• In infants and elderly patients, monitor respiratory rate and blood pressure.
• If convulsion continues after the second dose, treat as status epilepticus.

The patient is no longer seizing

– Look for the cause of the seizure and evaluate the risk of recurrence.

– Keep diazepam and glucose available in case the patient starts seizing again.

Status epilepticus

Several distinct seizures without complete restoration of consciousness in between or an uninterrupted seizure lasting more than 30 minutes.

– Protect from trauma, loosen clothing, maintain airway and administer oxygen as required.

– Insert an intravenous or intraosseus line.

– Administer 5 ml/kg of 10% glucose by IV (over 2 to 3 minutes) in children and 1 ml/kg of 50% glucose by slow IV (over 3 to 5 minutes) in adults.

– If 2 doses of diazepam have not stopped the seizures, use phenytoin or phenobarbital if phenytoin is not available or if seizures persist despite phenytoin.
 There is a high risk of hypotension, bradycardia and respiratory depression, especially in children and elderly patients. Never administer these drugs by rapid IV injection. Monitor heart rate, blood pressure and respiratory rate every 15 minutes during and after administration. Reduce the infusion rate in the event of a drop in blood pressure or bradycardia. Ensure that respiratory support (Ambu bag via face mask or intubation, etc.) and IV solutions for fluid replacement are ready at hand.

phenytoin
slow IV infusion

250 mg in 5 ml ampoule
(50 mg/ml)

– Children 1 month and over and adults: one dose of 15 to 20 mg/kg administed over 20 minutes minimum and 60 minutes maximum

– The concentration of the diluted solution should be between 5 and 10 mg/ml. The infusion rate should not exceed 1 mg/kg/minute or 50 mg/minute (25 mg/minute in elderly patients or patients with cardiac disorders).

For example:
Child weighing 8 kg: 160 mg (20 mg x 8 kg), i.e. 3.2 ml of phenytoin in 17 ml of 0.9% sodium chloride over 30 minutes
Adult weighing 50 kg: 1 g (20 mg x 50 kg), i.e. 20 ml of phenytoin in a bag of 100 ml of 0.9% sodium chloride over 30 minutes

Do not dilute phenytoin in glucose. Do not administer via a line used for glucose solution administration. Use a large catheter. Check the insertion site and for blood backflow (risk of necrosis in the event of extravasation). After each infusion, rinse with 0.9% sodium chloride to limit local venous irritation.

phenobarbital
slow IV infusion

200 mg in 1 ml ampoule
(200 mg/ml)

 

− Children 1 month to < 12 years: one dose of 15 to 20 mg/kg (max. 1 g) administered over 20 minutes minimum
If necessary, a second dose of 10 mg/kg may be administered 15 to 30 minutes after the first dose.

− Children ≥ 12 years and adults: one dose of 10 mg/kg (max. 1 g) administered over 20 minutes minimum
If necessary, a second dose of 5 to 10 mg/kg may be administered 15 to 30 minutes after the first dose.

− Do not administer more than 1 mg/kg/minute.

For example:
Child weighing 8 kg: 120 mg (15 mg x 8 kg), i.e. 0.6 ml of phenobarbital in 20 ml of 0.9% sodium chloride over 20 minutes
Adult weighing 50 kg: 500 mg (10 mg x 50 kg), i.e. 2.5 ml of phenobarbital in a bag of 100 ml of 0.9% sodium chloride over 20 minutes

For doses less than 1 ml, use a 1 ml syringe graduated 0.01 ml to draw the phenobarbital.

Further treatment

Febrile seizures

– Determine the cause of the fever. Give paracetamol (see Fever).
– In children under 3 years, there is usually no risk of later complications after simple febrile seizures and no treatment is required after the crisis. For further febrile episodes, give paracetamol PO.

Infectious causes

Severe malaria (Chapter 6), meningitis (Chapter 7), meningo-encephalitis, cerebral toxoplasmosis (HIV infection and AIDS, Chapter 8), cysticercosis (Cestodes, Chapter 6), etc.

Metabolic causes

– Hypoglycaemia: administer glucose by slow IV injection to all patients who do not regain consciousness, to patients with severe malaria and to newborns and malnourished children. When possible, confirm hypoglycaemia (reagent strip test).

Iatrogenic causes

– Withdrawal of antiepileptic therapy in a patient being treated for epilepsy should be managed over a period of 4-6 months with progressive reduction of the doses. An abrupt stop of treatment may provoke severe recurrent seizures.

Epilepsy

– A first brief seizure does not need further protective treatment. Only patients with chronic repetitive seizures require further regular protective treatment with an antiepileptic drug, usually over several years.

– Once a diagnosis is made, abstention from treatment may be recommended due to the risks associated with treatment. However, these risks must be balanced with the risks of aggravation of the epilepsy, ensuing seizure-induced cerebral damage and other injury if the patient is not treated.

– It is always preferable to start with monotherapy. The effective dose must be reached progressively and symptoms and drug tolerance evaluated every 15 to 20 days.

– An abrupt interruption of treatment may provoke status epilepticus. The rate of dose reduction varies according to the length of treatment; the longer the treatment period, the longer the reduction period (see Iatrogenic causes). In the same way, a change from one antiepileptic drug to another must be made progressively with an overlap period of a few weeks.

– First line treatments for generalised tonic-clonic seizures in children under 2 years are carbamazepine or phenobarbital, in older children and adults sodium valproate or carbamazepine.
For information:

sodium valproate PO
Children over 20 kg: initial dose of 200 mg 2 times daily irrespective of weight; increase the dose progressively if necessary until the optimal dose has been reached (usually 10 to 15 mg/kg 2 times daily).
Adults: initial dose of 300 mg 2 times daily; increase by 200 mg every 3 days if necessary until the optimal dose has been reached (usually 500 mg to 1 g 2 times daily).

carbamazepine PO
Children 1 month and over: initial dose of 5 mg/kg once daily or 2.5 mg/kg 2 times daily; increase the dose every week by 2.5 to 5 mg/kg, up to 5 mg/kg 2 to 3 times daily (max. 20 mg/kg daily) 
Adults: initial dose of 100 to 200 mg once or 2 times daily; increase the dose every week by 100 to 200 mg, up to 400 mg 2 to 3 times daily (max. 1600 mg daily) 

phenobarbital PO
Children: initial dose of 3 to 4 mg/kg once daily at bedtime; increase the dose progressively up to 8 mg/kg daily if necessary
Adults: initial dose of 2 mg/kg once daily (max. 100 mg); increase the dose progressively up to 6 mg/kg daily if necessary



Footnotes
Ref Notes
1

 For rectal administration, use a syringe without a needle, or cut a nasogastric tube, CH8, to a length of 2-3 cm and attach it to the tip of the syringe.