Page 314 - Medicine and Surgery

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310 Chapter 7: Nervous system

mostclassically30minutes;however,treatmentisstarted Table 7.8 Choice of AEDs in different types of epilepsy
at 15 minutes in order to avoid brain damage or death.
2nd choice
Status epilepticus is a medical emergency which carries Type of seizure 1st choice drugs drugs
a 10–15% mortality.
Generalised tonic–clonic Sodium valporate Phenytoin ∗
General measures include airway protection, oxygen
Carbamazepine ∗ Levetiracetam
and intravenous access. Lamotrigine
Urgentbloodtestsasabove,includingclotting,arterial Generalised Sodium valporate Ethosuximide
blood gas and save 50 mL serum (for later analysis of Nonconvulsive Lamotrigine Lamotrigine
anti-epileptic drugs (AEDs) levels, drug screen, alcohol (Absence)
Myoclonic Sodium valproate Clonazepam
for example).
Lamotrigine
Ensure any usual AEDs given. Partial seizures Carbamazepine ∗ Phenytoin ∗
Consider i.v. glucose (and i.v. thiamine). Sodium valproate Gabapentin
Lorazepam or diazepam are first-line treatment
Lamotrigine Topiramate
If no response, intravenous phenytoin loading dose
Tiagabine
Levetiracetam
of 15 mg/kg is given.
Ifstillin‘refractorystatus’(morethan60minutesof ∗ High dose oral contraceptive pill should be used and high dose folic

seizures, or >30 minutes after phenytoin) thiopen- acid for women of child-bearing age as these and phenobarbitone are
enzyme-inducing AEDs. Avoid valproate in women planning pregnancy.
tone or propofol are used (anaesthetic agents)
Women on enzyme-inducing AEDs should also have vitamin K in the
preferably with EEG monitoring to demonstrate ef- month prior to delivery to reduce the risk of neonatal haemorrhage
fectiveness, and endotracheal intubation and trans- caused by inhibition of vitamin K transplacental transport.
fer to an intensive care unit is required.
Following recovery from status epilepticus, long-

General advice includes avoidance of certain sports
term anti-epileptic medication should be reviewed
such as rock-climbing, unless seizures are well-
or initiated.
controlled; swimming is safe as long as supervised; and
bathroom doors should be left unlocked.
Initiation of treatment Driving: If a patient has had one or more seizures
Anti-epileptic drugs (AEDs) should be tailored to the they are not allowed to hold an ordinary Category 1 UK
individual (see Table 7.8). driving licence until seizure-free for 1 year. However, if
Neurosurgery is rarely undertaken except in selected attacks only occur whilst asleep and this pattern is es-
patients, with persistent, frequent seizures where there is tablished for 3 years, patients can drive even if seizures
a significant adverse impact on quality of life, with poor continue. Following a provoked seizure, e.g. due to head
control by medication and a clear electrical focus. Proce- injury, stroke, cranial surgery but excluding drugs or al-
dures include local resection, lobectomy, hemispherec- cohol, the suspension may be shorter. Patients should
tomy and in some cases, less invasively by stereotactic be advised to contact the DVLA. The DVLA also advise
radiosurgery. patients not to drive whilst any reduction of their medi-
cation takes place for 6 months after each change.
Depending on any underlying cause and absence of
Prognosis
EEG changes, anticonvulsant therapy can be discontin-
Most people with epilepsy are able to lead a normal ac-
ued if they have been free of an attack for 2–3 years.
tive life with medication to control their seizures, and
continue their education and work. The management
of epilepsy should include the discussion of social is- Acute confusional state (delirium)
suessuchassupportathome,relationships,employment
andpsychologicalissuessuchasdepression.Womenwho Definition
wish to become pregnant need special advice, but there Rapid onset of global but fluctuating confusion with an
is no reason why they should not have children. There underlying toxic, vascular, ictal (seizure) or metabolic
are support groups available. defect.