Epilepsy resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Fahimeh Shojaei, M.D., Moises Romo, M.D.

Synonyms and keywords: Epilepsy management, Epilepsy workup, Epilepsy approach, approach to Epilepsy, Epilepsy treatment

Overview[edit | edit source]

Epilepsy is a common chronic neurological disorder that is characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain. Epilepsy can be diagnosed based on history, symptoms and physical examination of a patient with seizure complain. Among the patients who present with clinical signs of seizures, the EEG is the most efficient test for diagnosis. Anti-seizure medications for epilepsy include drugs that affect voltage-dependent Na+ channels, drugs that affect Ca currents, drugs that affect GABA activity, drugs that affect glutamate receptor, and drugs with multiple mechanisms of action.

Causes[edit | edit source]

Life-threatening Causes[edit | edit source]

Life-threatening causes of epilepsy include:^{[1][2][3][4][5][6]}

• Head trauma
• Brain tumor
• Brain hemorrhage
• Encephalitis
• Hypoglycemia
• Hypoxic encephalopathy
• Stroke

Common Causes[edit | edit source]

Common causes of epilepsy may include:^{[7][8][9][10][11][12]}

• Cerebral palsy
• Electrolyte disturbances
• Epileptic encephalopathy - Lennox-Gastaut type
• Febrile seizures
• Huntington's disease
• Intoxication
• Uremia

Diagnosis[edit | edit source]

Shown below is an algorithm summarizing the diagnosis of Epilepsy according the the ESC guidelines:

Treatment[edit | edit source]

Shown below is an algorithm summarizing the treatment of epilepsy according the the American Epilepsy Society guidelines:^[13]

• Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose,
Level A) OR

• Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose
once, Level A) OR

• Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose
once, Level A)

• Intravenous phenobarbital (15 mg/kg/dose, single-dose, Level A) OR

• Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR

• Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose,
Level U) OR

• Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose,
Level B) OR

• Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single-dose, Level U)

Do's[edit | edit source]

• Adults with an unprovoked first seizure should be informed that their risk of recurrence is higher within the first 2 years.^[14]
• Treat with immediate antiepileptic therapy from the first unprovoked seizure in adults, since it has been seen that it reduces recurrences, as compared with the delay of treatment pending a second seizure. This may not improve quality of life.^[14] Benefits and risks of psychological and medical side effects of AED should be evaluated when treating children with an unprovoked first seizure.^[15]
• Use Gabapentin in patients aged ≥60 years with new-onset focal epilepsy, as it is as effective and better tolerated than other drugs.^[16]
• Lamotrigine should be used to decrease seizure frequency in patients aged ≥60 years.^[16]
• Vagus nerve stimulation may be used to reduce seizure frequency over time for periods greater than 6 months and as long as 12 years. In adult patients receiving VNS for epilepsy, improvement in mood may be an additional benefit.^[17][18]
• Adjust dose of antiepileptic drugs in pregnant, since pregnancy may increase the risks of seizure.^[19]
• Adjust dosage of antiepileptics such as phenytoin and valproic acid in patients with HIV taking certain antivirals.^[20]

Don'ts[edit | edit source]

• Do not restrain a person with a seizure to try to stop his or her movements.^[21]
• Do not put anything object in a person’s mouth during a seizure, since it may injure his teeth or the jaw.^[21]
• Do not give water or food to a person with a seizure until he or she is fully alert.^[21]
• Do not use cannabinoids in epilepsy. Although, marihuana has been suggested to decrease seizure frequency in epilepsy, there is insufficient studies to support or refute its efficacy.^[22][23]

References[edit | edit source]

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