Seizures

A seizure is an abnormal, sudden, involuntary muscle clonus caused by abnormal electrical activity in the brain. Seizures are common, with up to 3% of the population experiencing 2 or more seizures in their lifetime. Strictly, epilepsy is a recurrent tendency to spontaneous intermittent seizures, and patients should not be labelled as ‘epileptic’ after their first seizure.

Causes of seizures:

• Head injury (immediate or delayed)
• Intracerebral bleed
• Hypoglycaemia
• Meningitis or encephalitis
• Metabolic disturbance (e.g. low serum sodium)
• Cerebral tumour
• Epilepsy

Symptoms and signs:

• May be preceded by visual, auditory or olfactory aura - minutes before
• Generalised or local tonic +/- clonic activity
• Urinary +/- faecal incontinence
• Tongue biting
• A post-ictal period. The seizure will have stopped and the patient remains sleepy with low GCS. This may last minutes to hours, but should be improving over time.

Management of seizures:

Check for safe approach, A B(& O2)C D E; in particular:

Airway - This will frequently be obstructed. A head tilt & chin lift, or jaw thrust will usually open the airway. Occasionally a fitting patient will have trismus, if this occurs a nasopharyngeal airway will be invaluable. Remember oxygen 15 L/min via a non-rebreathe mask.

C-spine control - This may well be impossible to safely achieve during a seizure. Never hold or attempt to restrain a patient during a seizure.

Breathing - A fitting patient may hypoventilate, but supporting ventilation during a tonic-clonic seizure can be difficult. Priority must be given to ensuring that a patent airway is established and high flow oxygen is administered to the patient via a non-rebreathe mask.

Circulation - A seizure does not usually cause significant haemodynamic compromise, although the patient will frequently be tachycardic during and for a period after the fit. IV access can be challenging and if not immediately available, other methods of drug administration should be considered e.g. buccal midazolam or rectal diazepam.

Definitive treatment:

Most seizures will self-terminate within a few minutes. It is reasonable to use this time to ensure the airway is patent, that oxygen is being delivered to the patient, and to check the capillary blood glucose (CBG). If the CBG is low, this should be corrected as described earlier in the chapter. If the seizure does not self-terminate, it may be necessary to administer drug therapy. It is important to be mindful of the potential complications of benzodiazepines, and to be ready to deal with any of these, most importantly respiratory depression or arrest.

• Rectal or IV diazepam 10 mgs
• Buccal Midazolam
• IV midazolam (lorazepam is usually the choice in the hospital setting, but needs to be kept refrigerated so unlikely to be available in the pitch side setting).
• Check capillary blood glucose (CBG) and treat if hypoglycaemic

Refer to an Emergency Department as soon as possible.