First Fit

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First Fit

• Dr Viviana Elliott
• Consultant Physician
• Acute Medicine

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Aim

• To provide an algorithm for the early management
  of adults with first seizure

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Objectives

• To be able to recognise seizure
• To be able to approach investigations and treat
• To be able to safely discharge if appropriately
• Management of status epilepticus

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Incidence

• 0.24 0.3 of adults who present to the ED
  department
• 3 of the population will experience a non
  febrile seizure during their life time

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Definition of Seizure

• Physiological occasional, excessive rapid and
  local discharges of grey matter
• Clinical intermittent, stereotyped, disturbance
  of consciousness, behaviour, motor or sensory
  function resulting on clinical grounds from a
  neuronal discharge
• Epilepsy is the spontaneous recurrence of such
  events

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• prevalence 7/1000
• incidence 50/100.000
• 400.000 people with epilepsy in the UK of whom
  160.000 need ongoing management
• lifetime risk of having a spontaneous seizure is
  2-5
• only 20-30 of patients coming to an epilepsy
  clinic with a seizure actually had a genuine
  seizure, 60-70 had a faint

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What to ask...patient and eye witness is crucial
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Differential Diagnosis

• Blackouts
• Simple faint (vasovagal syncope)
• Cardiac syncope
• Postural hypotension
• Hypoglycaemia
• Non-epileptic attacks (pseudoseizure)
• Attacks with focal neurology
• Transient ischemic attack
• Migraine

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Syncope

• Typical warning ( unless cardiac cause)
• Often external triggers
• Collapse, usually motionless, short
• Myoclonic jerks may occur stimulating a
  generalise tonic clonic
• Incontinence can occur ( full bladder)
• Recovery rapid without confusion

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Non-epileptic seizure

• Difficult to accurate diagnose and usually
  require video
• Diagnosis should be made by specialist
• Often mixed with epileptic seizure
• Consequence of incorrect labelling of condition
  extensive

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Emergency treatment of seizure

• A-E approach
• Check for treat hypoglycaemia, hypoxia
• electrolyte disturbances and acidosis
• Pabrinex if suspected alcohol misuse
• Self terminating, brief, single seizure do not
  require treatment

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Investigations of seizures

• Routine bloods
• FBC
• UEs
• LFTs
• Bone chemistry
• Mg
• Glucose
• GamaGT
• ECG
• ? Urine drug screen

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Patient with self terminating generalised seizure
and full recovery

• Discharge home if observations, bloods, ECG and
  CT brain (if done) are normal
• Book urgent appointment with first fit clinic
  without requesting further investigations
• Advice the patient to stay with a responsible
  adult
• Discuss starting treatment with on call SpR if
• Previous generalised tonic clonic seizures
• Additional seizure type eg myoclonic jerks
  , partial
• seizure

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Advice before dischrge

• Life style changes
• The Driving and Vehicle Agency (DVLA) states that
  following a first epileptic seizure/ solitary
  fit, drivers group 1 ( cars and motorcycles)
  should remain from driving for a year with
  subsequent medical review

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Patient with known epilepsy and a flurry of
seizures

• Check compliance
• Intercurrence infection/ alcohol/ sleep
  deprivation
• Drug levels
• READ PREVIOUS LETTERS
• Can increase anti epileptic drugs, especially
  evening dose
• Consider adding clobazam 10-20 mg BD for 3/7

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CT head if red flags

• Middle age/ elderly
• More than 1 seizure
• Pregnancy or post partum
• New focal neurology deficit
• Persistent altered mental status
• Fever or persistent headache
• Recent head trauma
• History of cancer or HIV
• Focal or partial onset seizure
• Anticoagulation or bleeding diathesis
• Past history o stroke or TIA

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Convulsive status epilepticus
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Convulsive status epilepticus

• Definition
• a condition in which convulsive epileptic
  activity persists for 30 minutes or more. Can be
  single prolonged or recurrent GTC without
  clinical recovery in between
• Most seizures last lt 2 minutes, average 1 minute
• The longer the seizure the more refractory to the
  treatment they become
• Seizures lasting more than 5 minutes should be
  address as impending status
• Look for local guidelines

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Aetiology of status epilepticus

• 34 low concentration of Anti Epileptic Drugs
  with chronic epilesy
• 22 CVA
• 10 hypoxia / anoxia
• 10 metabolic
• 10 alcohol and drug withdrawal

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Convulsive status epilepticus

• A-E approach
• Maintain airway and BP
• Give anticonvulsivants
• Examine the patient!!!!
• Think of underlying causes and treat if possible
• hypoxia./ischemic ( high mortality)
• Enchephalitis, alcohol, metabolic
• Secondary generalised from abscess or tumour
• Stroke common in elderly
• Low Anti Epileptic Drug levels common in known
  epilepsy

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Management of Tonic Clonic Seizures

• Alternative options if difficult IV access
• Diazepam 10 mg rectal
• Midazolam 5-10 rectal/buccal/im

Seizure gt 5-15 min
ABC 100 Oxygen BM Drug Level Biochem FBC
Glucose True status?
Seizure continues
Lorazepam IV 4 mg over 2 min
Further Lorazepam IV 4 mg over 2
min AND Phenytoin 15-20 mg/kg at 50 mg/min with
cardiac monitor then 100 mg tds AND Alert ITU
Seizure stopped

• Establish cause unless previously establish
• Establish and review maintenance treatment
• Discuss with neurology

Seizure continues
Refer immediately to ITU
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Take home points

• Context of the attack eg witness history
• What kind of seizure?
• Look for precipitants or red flags
• A- E approach
• Lorazepam best first choice
• Give 20mg/kg Phenytoin no less if indicated !!!
• Intubation / ITU saves lives but has risks

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Questions?
Thank you !