Epilepsy is a clinical syndrome characterised by the presence of recurrent seizures. Seizures are result of excessive electric impulses discharge of cerebral neurones.

Classification

Partial

• Simple partial seizures; can be motor, sensory and sensory-motor (consciousness not impaired)

• Complex partial seizures; starting with an aura (later impairment of consciousness) and often accompanied by automatic behaviour

• Partial seizures becoming progressive (Jacksonian seizures) or generalised.

Generalised seizures

• Initially generalised;

- absence seizures

- tonic seizures

- myoclonic seizures

- tonic-clonic seizures

- clonic seizures

- atonic seizures.

Clinical Features

Meticulous history from patient and reliable witness is critical in diagnosing a seizure disorder. Ask about the prodromal phase, aura and the type, duration, frequency and the age of onset of seizures. Detail about the post ictal phase are important. Ask about precipitating factor e.g. alcohol use.

Investigations

• Skull X-ray: All cases for possible radiolucent focal lesion, raised intracranial pressure

• Full haemogram

• Malaria parasites (MPs) especially in children

• Blood sugar, urea and electrolytes in cases where metabolic conditions are considered as a cause of a seizure disorder

• Fundoscopy in newly diagnosed patients

• CT scan should also be considered.

Management - Acute

• During an epileptic attack:

- patient should be placed on the left lateral position with head turned to the same side;

- tight fitting dresses around the neck should be removed

- dentures should be removed

- no attempt should be made to insert any instrument into the mouth to avoid tongue bitting as this may have already happened

- patient should not be surrounded by too many eager observers

- seizures should be allowed to complete its course without physically attempting to hold down the patient. However, remove patient from danger e.g fire

• After an attack:

- patient should be investigated as outlined above and started on therapy.

Management - General

• Treat underlying diagnosed condition if possible e.g. hypoglycaemia, meningitis

• Establish firm diagnosis before starting therapy

• Most patients can be started on therapy as outpatients

• Start therapy if patient has had two or more seizures within one year

• Treatment is usually life long. Therapy may be discontinued after a seizure free period of at least two years. Reduce dose gradually over many months. Sudden discontinuation of drugs may precipitate status epilepticus. Complex partial seizures will require lifelong drugs

Management - Pharmacologic

• Start therapy with one drug, usually phenobarbitone. Increase at regular intervals until seizures are controlled or side effects appear. If side effects appear and fits are still not controlled, introduce other drugs and taper off the first drug.

Drugs of choice for common seizures

PAEDIATRIC SCHEDULE

NB: Sodium valpoate is the most broad spectrum anticonvulsant but it is very costly and is better used as second line drug

Admit For

• If underlying metabolic cause is suspected or raised intracranial pressure is present.

Refer If

• Seizures not controlled with maximum drug dose
• Raised intracranial pressure is suspected.

Patient Education

• Avoid becoming drunk especially drinking spree during weekends
• Eat at regular intervals
• Stress, physical or mental may precipitate a fit, thus manage stress
• Avoid sleep deprivation
• Never swim alone and all precautions should be taken when swimming
• Avoid operating heavy or sharp edged machinery
• To prevent burns, protective shield should be made around "jikos"(braziers)

STATUS EPILEPTICUS

A succession of seizures without regaining consciousness in between attacks. It could be due to partial, complex partial, absence, tonic-clonic or clonic. Only the latter two are life threatening.

Clinical Features

Patient is not able to talk, the tonic phase is not clear and the patient appears in continuous clonic phase, the short tonic phases being difficult to see. May be in respiratory embarrassment with cyanosis or may be hypoglycaemic.

Management - Supportive

• Place patient by the side (lateral position). Do NOT attempt to put anything into the patient's mouth to stop the biting of the tongue. You are likely to cause more damage.

Drugs

Give IV (not IM) diazepam 10 mg STAT, repeat if there is no response. The injection rate should not be faster than 3 minutes. If still no response put 80 mg in 500 mls of N/saline, adjust rate to control seizures. Children: 0.2-0.5 mg/kg in 5 minutes (max. 10 mg in 1-3 yrs and 15 mg in 3-15 yrs.). Repeat after 15 minutes if not controlled.

• Rectal diazepam 10-20 mg may be as effective. Children: 0.5-0.7 mg/kg.

Use rectal solution at 0.5 mg/kg

• OTHER useful drugs include:

- phenobarbitone.

Adults: Loading dose 10 mg/kg IV at a rate of 100 mg/minute. Maintenance 1-5 mg/kg/day PO or IV. 3-6 mg/kg IM BD or TDS. Then maintenance 1-5 mg/kg/day.

Children: Loading dose 10 mg/kg IV in 5 minutes. If no response repeat 10 mg/kg (Max. 20 mg/kg). Maintenance dose 3-8 mg/kg/day.

• IV Phenytoin (with glucose-free solution, seek senior guidance). Loading dose 18-20 mg/kg. Infusion not to exceed 50 mg/minute. Maintenance 300-500 mg/day.

Children: 20 mg/kg once.

• Clonazepam by slow intravenous injection 1 mg

Maintain normal acid base status: Give NAHCO3 4.2% solution IV at 2 ml/kg.

Refer If

• No response to drip or respiratory depression appears after the doses required to control the seizures.

FEBRILE CONVULSIONS

This diagnosis should be made by exclusion of all other causes of convulsions. It is a form of generalised tonic-clonic seizure seen characteristically in childhood and meeting the following diagnostic criteria: Occurrence in infancy or early childhood, usually between ages 6 months and 5 years. Fever at the time of the attack, usually greater than 38°C. Brief duration (always less than 15 minutes). Absence of CNS infection and absence of neurological abnormalities in the inter-ictal period.

Investigations

• Lumber puncture and CSF examination
• Blood slide for MPs
• Exclusion of intoxication by history
• If diarrhoea and vomiting: Urea & electrolytes.
• Blood for C&S.

Management

• Acute:

- antipyretic measures including tepid sponging and antipyretic medication (avoid use of salicylates: underlying fever may be influenza or varicella)

- anticonvulsant drug therapy unnecessary.

• Subsequent:

- institute phenobarbitone therapy after second or third febrile convulsion especially if seizures are triggered by only modest rises in body temperature. Tail off therapy if seizure free for 2 years.