Contents:

• Seizure type
• Differentials
• Treatment of Status (Generalised, Focal, Absence)

Seizure Types

Non-epileptic (NES)– this can be a difficult area for healthcare staff, as this presentation can be very broad, including:

• ‘Factitious’ variant – where the patient has an element of control
• ‘Dissociative’ varient – where the patient has NO control

It is worth noting that 10-20% of epileptics will also experience NES. Generally NES occurs at times of stress, whether psychological, social, or illness.

The fits themselves vary greatly, from obvious control to indistinguishable from a generalised seizure. However, some of the following features could be used to distinguish them, although there is no single feature that is diagnostic.

• Conscious control
• Movements tend to have a greater amplitude
• Side-Side head movement
• Eyes closed
• Plantars down going – this can be difficult o perform during a seizure
• Lactates may be lower – however, this is not reliable (as they are doing a lot of exercise)

Treatment there is no Emergency treatment beyond, supportive. However, as these can be almost indistinguishable from generalised seizures we likely treat plenty these fits along the STATUS protocol already, which is probably appropriate due to the risks involved with not treating a generalised seizure.

• Epilepsy Society
• GOSH
• Non-Epileptic Attacks

Generalised – electrical seizure activity occurs throughout the brain producing the typical tonic-clonic seizure. The patient is unresponsive, all limbs stiff and tremulous. normally will self terminate within 2 mins.

Focal Onset- these fits are localised to one area of the brain, or at least start that way. Focal onset seizures are divided into 2 types (modern nomenclature uses “aware” or “impaired awareness”)

• Simple/Aware: One stereotypical seizure pattern e.g one arm shaking with no escalation and patient aware and conversant throughout.
• Complex/Impaired Awareness: The normally starts as above but then escalates, this may present as poorly responsive, lip smaking or mumbling nonsense, to full tonic-clonic seizure

Absence – episode of unresponsiveness, which can often be missed or dismissed as day dreaming. short video here

Differentials:

The following are potential causes of seizure and are worth considering, as many of them will need to be treated concurrently.

• Unknown  (1/3)
• Epilepsy
• Brain injury
  • Trauma
  • Mass
  • Stroke
  • Infection (meningitis, encephalitis)
• Electrolyte abnormality (hyponatraemia)
• Hypoglycaemia
• Hypoxic
• Fever 6m-6y
• Drugs

Status Treatment

We would all treat a Tonic-Clonic Status, however, all the seizure types can present with status. Remember that electrical storm is present in all types and requires treatment.

Generalised/Focal Onset Impaired Awareness

1. Support (make sure patient safe, and ensure supportive care started)
2. Glucose (2ml/kg-kid or 250ml-adult 10% glucose)
   • + Thiamine in adults due to risk of Wernicke’s (100mg IV thiamine recommended, easiest source Pabrinex part 1)
3. Benzodiazepine @5min – in patients receiving 1st benzo’s after 10mins there is an increased mortality/morbidity
   • Rp tafter 5 min
   • Consider Paralderhyde (some of our paediatric patients will have a management plan that include paraldehyde its important to check)
4. Phosphenytoin/Phenytoin[20mg/kg (max. 2000mg) 20min]
   • ECG monitoring required
   • Purple Glove Syndrome
   • Levetriacetam/Valproate being used instead in other centres
5. General Anaesthetic – remember muscle relaxants work well to disguise seizure activity

Hyponatraemia

• Seizures more likely <120mmol/l, and are unlikely in chronic hyponatraemia the risks of correction are not as much of a concern.
• No brilliant guidance available – but initially should be standard Status therapy
  • Adults: 100ml bolus 3% NaCl (10min), can repeat x 2 – from WFSA
  • Kids: various sources indicate 4ml/kg of 3% NaCl (20min) bolus is reasonable, and definitely involve paediatrics. Royal Children’s Hospital Melbourne, Management of hyponatremic seizures in children with hypertonic saline: a safe and effective strategy. 
  • Central Access – Several sources recommend 3% NaCl should ideally be given via central line, which seems appropriate in the adult setting, however, may cause significant delays in our paediatric population.
• Aims
  • Terminate fit
  • Na>120-125

Focal Onset Aware

1. Support
2. Treat Cause – e.g. abscess, tumour
   • Glucose and Thiamine [RARE – hypoglycaemia is unlikely to cause this form of seizure]
3. Benzodiazepine (@5min)
4. Anti-Epileptic – this may terminate the fit but more importantly is thought to prevent propagation
   • Phos/Phenytoin[20mg/kg (max. 2000mg) 20min]
   • Levetriacetum[30mg/kg (max 3000mg) 15min]
5. General Anaesthetic [RARELY required]

Absence

this would be difficult to diagnose without collaborative hx from family or friends, as the patient would just appear catatonic but its important we are considering this

1. Support
2. Glucose – thiamine not required as this won’t be Wercicke’s
3. Benzodiazepine (@5min) – Warning there is an increased risk of apnea
   • Consider Rpt after 5 min
4. Levetriacetum/Valproate[30mg/kg (max 3000mg) 15min]
   • NOT – Phenytoin/Phosphenytoin

Further reading, BMJ Best Practice guidance on:

• Generalised Seizure
• Focal Seizure
• Status Epilepticus

(you can download the PDF’s but does require ATHENS login)