Seizures

• Seizures are a result of abnormal electrical conductions in the brain causing the sudden onset of transient neurological symptoms.
• Generalised convulsive status epilepticus is defined by continuous seizures lasting ≥ 5 minutes, or ≥2 discrete seizures between which there is incomplete recovery of consciousness (Brophy et al., 2012).
• Status epilepticus is a medical emergency, and convulsive seizures can be very distressing to family members..

In the palliative care setting, the common causes of seizures include:

• Structural brain lesions e.g. primary or secondary brain tumour, acute or chronic strokes, hypoxic ischemic brain injury, traumatic brain injury
• Inflammatory brain disorders e.g. meningo-encephalitis, autoimmune encephalitis
• Metabolic or electrolyte disturbances e.g. uraemia, hyperammonaemia, acidaemia, severe hyponatraemia
• Medications known to lower seizure threshold, or lower the efficacy of antiepileptic drugs(AEDs)
• Sub-therapeutic levels of antiepileptic drugs 
  

•  Aim for termination and prevention of seizures
• Provide a calm and reassuring presence to the patient and family members
• Family members should be encouraged to ‘remain outside’ till the situation is under control and reassurance is given
• Place patient in recovery position
• Give supplemental oxygen if available
• Time onset of seizures
• Consider reversal of underlying causes:
  a) To start/review dexamethasone if there is suspicion of brain metastases with cerebral edema
  b) Consider Thiamine in patient with suspected chronic alcoholism
  c) Review AED drugs and dosages
• Discontinue medications that can lower seizure threshold (e.g. Imipenem, Cephalosporins, Haloperidol). 
• Place patient in recovery position
• Give supplemental oxygen if available 
• If a seizure persists for 5 minutes or more, or is recurrent, pharmacological management of seizures should be initiated. 
• If a seizure takes place at home, institute the following pharmacological management, and consider admission to hospital or inpatient hospice if appropriate.
  

• Rectal Diazepam 10mg can be given if immediately available
• Parenteral Midazolam 5mg  can be given every 15 minutes until the seizure is aborted. 
• If seizures persist, a parenteral (IV/SC) Midazolam continuous infusion (range from 1-3mg/hr) can be started OR consider other parenteral antiepileptics (e.g. Levetiracetam, Sodium Valproate or Phenobarbitone)
• For refractory status epilepticus,  urgent referral to a neurologist or specialist palliative team should be considered
  

• Droney J, Hall E. Status Epilepticus in a Hospice Inpatient Setting. J Pain Symptom Manage. 2008;36(1):97–105.
• Golf M, Paice JA, Feulner E, O'Leary C, Marcotte S, Mulcahy M; Refractory Status Epilepticus. Palliat Med. 2004;7(1):85–88.
• Twycross R, Wilcock A, Howard P, eds. Palliative Care Formulary. 5TH ed. Nottingham, UK: palliativedrugs.com Ltd; 2014.