In the management of a patient exiencing focal or generalised motor seizures, it is helpful to have a discussion with a Consultant Neurologist and/or senior clinician prior to initiating or discontinuing anticonvulsant  medication.  Local Health Authority seizure protocols should also be consulted.

 

 

Emergency Management
If immediate seizure control is required (i.e. the seizure is not spontaneously self-terminating) follow your local emergency care protocol:

General principles of management or treatment escalation include:

  • Ensure safe position/remove hazards.
  • Check airway, breathing, circulation and temperature.
  • Identify and following pre-set treatment plan where possible:shutterstock_280508981
    • Check for “medic-alert” bracelets/tags or patient held prescription records.
  • Check glucose levels.
  • Call emergency number for assistance.
  • Administer oxygen.
  • Administer Buccal Midazolam or Rectal Diazepam (if trained in use).
  • Establish intravenous access.
  • Administer intravenous Diazepam (if trained in use and have access to mechanical ventilation and Flumazenil).
  • Take blood for full blood count, renal and liver function tests, calcium, glucose, coagulation screen and anticonvulsant levels.

If seizures are recurring one after the other:

  • Follow your local emergency care protocol.
  • Consult with a Neurologist or senior clinician if necessary.
  • Consider administration of intravenous Phenytoin; the benefits include:
    • Early onset of effect.
    • It can be given intravenously.
    • The dose can be titrated against plasma level.

Once daily dosing may enhance compliance with oral medication when trying to establish the patient on the drug for long term management.  Problems with Phenytoin may include sedation in the short term. Longer term side effects can include:

  • Gum hypertrophy.
  • Acne.
  • Hirsuitism.
  • Facial coarsening.
  • Potential to interact with other medication.

If longer term seizure control is required (based on factors that indicate increased risk of seizure recurrence), follow local epilepsy protocols and/or consult a senior clinician and/or a Consultant Neurologist.

Medication options usually considered include Levetiracetem, Lamotrigine or Sodium Valproate.  Side effects of these medications include:

  • Gastrointestinal upset (All).
  • Sleep disturbance (All).
  • Drowsiness (All).
  • Headache (All).
  • Lightheadedness/dizziness/unsteadiness (All).shutterstock_234377257
  • Diplopia/Double Vision (Lamotrigine).
  • Ataxia.
  • Tremor (Valproate).
  • Weight gain (Valproate).
  • Hair loss (Valproate).
  • Blood disorders (Valproate/Lamotrigine).
  • Liver or endocrine abnormalities (Valproate).
  • Mood change or irritability (Levetiracetem).
  • Flu symptoms (Levetiracetem).
  • Rash, hypersensitivity or mucosal irritation (Lamotrigine).

Ensure the patient or carer knows and understands the reasons for treatment choices, potential side effects.

If considering long term medication, ensure that the patient or carer is advised about an escalation plan for use in the event of any future seizure.

Avoid interacting medications that may affect seizure threshold.
Please consult the British National Formulary for further information.