UNM COC:  Your Healthcare Primer for Long Term Care

 
Seizures

John Phillips, MD (pediatric neurologist)

Definition

Our brains are constantly active, with electricity buzzing from one neuron to the next in a magical symphony of existence; every feeling, thought, movement, and dream starts in the brain. Even during sleep our neurons are firing off. But when groups of neurons start firing together, again and again without letup, this is a seizure. Because seizures can occur anywhere in the brain anything can happen; some seizures cause the whole body to jerk uncontrollably, other seizures look like staring spells, some cause a sudden drop or stiffness, and still others are noticed only by the person having the seizure (seeing flashing lights, smelling pungent odors, part of the body going numb).

Introduction

Seizures are common—almost 10% of people will have a single seizure at some point in their lives. 1% of people have epilepsy, defined as more than one seizure without a clear cause. Luckily most seizures don’t cause brain damage, and because of the many treatments now available about 2/3rds of those with epilepsy are successfully treated. But despite our best treatment there are still many people who continue to have seizures. It is important to know what can be done for someone having a seizure, and when to call for help.

When a seizure occurs, neurons fire uncontrollably. This can be caused by any imbalance in the brain. Things like abnormal serum electrolytes (the salts in our blood), drug reactions, alcohol withdrawal, brain infections or even sleeplessness and psychological stress can be associated with seizures. Some causes of seizures can be avoided, like avoiding getting drunk or getting severely dehydrated. But many seizures come from differences in the brain some people are born with, or from injury to the brain after birth. These seizures may not be easily avoided and require medical treatment.

Several general types of seizures can occur. The type of seizure can often be identified by what a person does during the episode. Different types of seizures respond better to certain medications, so it is important that the treating physician know as much as possible about the seizure to be able to make the correct diagnosis and start appropriate treatment.

Diagnosis

Much of the diagnosis comes from knowing exactly what happens during the seizure. Basically, seizures can start out generalized (with the whole brain having a seizure from the beginning) or focally (when the seizure starts in a specific area of the brain). The important factor is how things started. So its not so important how the seizure ended, but rather how it began. And the difference between a generalized vs focal seizure disorder affects treatment.

Therefore a critical question is "what was the first thing that happened?" Some focal seizures quickly spread to the whole brain, and for example may start with a split second look to the left before the whole body starts convulsing. This would be a focal seizure with secondary generalization, not a primarily generalized seizure. So to diagnose the type of seizure, one needs to know whether the whole body was affected first (one of the primarily generalized seizures) or if only part of the body was affected (a focal, or as its also called, partial, seizure). If it is a partial seizure, the next question is whether there was any change in consciousness (did the person looked dazed or pass out) which would be a partial complex seizure, or if the person stayed wide awake through the episode which would be a partial simple seizure. Lastly, after it began, did the partial seizure change to involve the entire body (did it become secondarily generalized)?

When diagnosing a seizure disorder, the physician usually looks for specific causes with blood tests, sometimes spinal fluid analysis, head imaging studies (brain MRI---magnetic resonance imaging) and an EEG (electroencephalogram). But treatment can start right away, even before all the test results are back.

Treatment

Treatment depends on balancing several factors: the type of the seizure, what is causing it, how frequent it is occurring, the patient’s lifestyle and how severe the seizure is. But not all seizures have to be treated. Indeed, in some cases treatment causes side-effects and it is important that the side-effects are not worse than the seizures themselves.

Long ago people tried things like different herbs, fasting, and even dried gladiator blood in an effort to stop epilepsy. In the early 1900’s phenobarbital was found helpful, and in the 1920’s phenytoin (Dilantin) was discovered. In the second half of the last century valproic acid (Depakote) and carbamazepine (Tegretol) were approved for seizure control. And just in the past 10 years many new drugs have become available. Sadly, despite the large number of anti-seizure medications now available, up to 1/3 of patients with epilepsy remain poorly controlled. Many of these patients benefit from trying the newest medications available, or one of non-drug treatments such as the ketogenic diet, vagal nerve stimulator or surgery.

Medications are chosen based on seizure type. Often patients with generalized seizures start treatment with valproic acid, lamotrigine, phenobarbital, primidone, ethosuximide or clonazepam. Partial (focal) seizures may respond to carbamazepine, gabapentin, phenytoin, topiramate, tiagabine or zonisamide. Some medications work for several different seizure types, and for difficult to control seizures several medications at once are often required. The chart outlines commonly used antiepileptic drugs, their uses and potential side-effects.

For most seizure medications routine blood monitoring is often done. Side-effects can occur even with blood monitoring, but sometimes there are indications of problems developing before they become dangerous. In addition, blood levels can be checked for most of the older drugs, which can help with managing the medications.

Two non-drug treatments for epilepsy are the vagal nerve stimulator and the ketogenic diet. The vagal nerve stimulator is fairly new. It can help decrease most kinds of seizures, but requires a specialized epilepsy program to perform the surgery and manage the devise. Possible side-effects include operative complications, changes in voice quality, mechanical failure, or ineffectiveness. The ketogenic diet has been used for almost 100 years but only recently has become more commonly used. It also can improve most seizure types and in some cases can stop seizures entirely. Managing the diet requires a specialized team including an experienced dietitian. Side-effects can be just as significant as with any medication and include kidney stones, electrolyte imbalance, high blood lipids, or if "cheating" occurs prolonged seizures can result. Lastly, some seizures can be treated with surgery if a specific area of the brain is identified where the seizures come from. A comprehensive epilepsy program is needed to evaluate patients who may benefit from surgery, and to perform the necessary operation and follow-up patients afterwards.

Emergency Situations – What can go wrong?

Most seizures are not dangerous. They are usually short and cause no long-term problems. But sometimes a seizure won’t stop on its own within several minutes. These seizures, particularly if the entire body is involved (a generalized tonic-clonic or "grand mal" seizure), require prompt medical attention. When a generalized seizure lasts more than three to five minutes, 911 should be called so that more aggressive treatment can be given by the paramedics or when the patient arrives at the nearest emergency room.

In some cases medication is given to caretakers ahead of time so that if a seizure does last longer than several minutes, something can be given at home before paramedics arrive. Diazepam (Valium or Diastat) can be given rectally, through a feeding tube or even in the nose while a person is seizing. This is often enough to stop the seizure. Even if diazepam stops the seizure, though, a health care provider should be contacted to discuss whether further evaluation or treatment should be undertaken.

For any seizure, common sense is in order. The patient should be in a safe position, preferably laying down with his/her head turned to the side (this is for the rare instance when the patient vomits and is to keep it from going back down into the lungs). Note is made of the duration of the seizure and exactly what the person is doing—particularly at the onset—to help medical care personnel decide on the best treatment. This is usually all that needs to be done. During a seizure patients often have labored breathing. Only if a patient stops breathing would artificial respiration need to be done. Never put anything like a spoon into the person’s mouth. Once the seizure goes beyond three to five minutes an ambulance should be called.

Conclusion

Seizures are common, affecting all types of people of all ages. They are more often seen in patients with developmental disabilities. Fortunately most seizures are not harmful and do not require immediate treatment. Knowing which seizures do require immediate attention is an important part of epilepsy care and can avoid unnecessary trips to the emergency room. Planning ahead for a seizure can be helpful, such as writing out instructions for all caretakers in the event of a seizure or discussing a plan of action with the patient’s physician. In some cases this will include instructions on how to give rectal or intranasal medication for prolonged seizures. Because epilepsy is common, much research is being done to help develop more effective and safer treatments for people with seizures.

John Phillips, MD (pediatric neurologist)