Subsequent Seizures Seizure Exacerbations in Established Epilepsy

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The ideal situation would be for every member of the public to know how to manage a person having a seizure. However, because this is not the case, it is necessary to provide parents and caregivers with instructions once the diagnosis of epilepsy has been made. The instructions are straightforward, but because of the mythology surrounding epilepsy, it is necessary to provide them clearly. Above all, common sense should prevail. If the person in the seizure is at risk of injury, for example, if the head is bumping against a hard surface, then the head should be held in the hands of the caregiver or should be protected in some other way, for example, by placing a soft object beneath it. A rolled-up jumper or coat can serve this purpose. Other obvious safety precautions should be taken. For example, if someone is having a seizure in the road they need to be moved to a safer place. Objects should not be put into the mouth. This may result in the patient's teeth being broken or the caregiver's fingers being bitten. Contrary to traditional false information, it is not possible for a person to swallow his or her tongue during a seizure, but the tongue may fall back into the airway at the end of the seizure, causing obstruction and, for this reason, it is advisable to place the person in the recovery position after the seizure. Confusion sometimes arises because of the instruction to put the person in the recovery position. Of course this is impossible during a tonic-clonic seizure, but it is an important and worthwhile measure to take after the seizure, to encourage a clear airway and to allow any secretions to drain.

Apart from the first seizure (see previous section) medical attention should not be required in someone who is otherwise well, with the exception of two situations: a prolonged seizure/failure to recover adequately within a few minutes of a seizure or injury in the seizure. As already discussed, if the seizure is precipitated by an underlying illness, then medical attention may also be required. It is not necessary to call an ambulance or arrange for admission to hospital if the individual recovers promptly from the seizure and is conscious but simply tired. Brief postictal confusion is common. Sometimes this confusion may lead to "resistive violence"4: if the person is left to recover without being approached/touched, then this is unlikely to occur but if some people are approached closely or touched soon after a seizure, while still in a confused state, they may misinterpret these actions and the caregiver may be pushed away or struck. If postictal confusion is prolonged or particularly troublesome, medical attention might be required. Some individuals are liable to postictal psychosis.5 . This may occur after "a lucid interval" of several hours or a few days.6 Postictal psychosis is usually brief, typically lasting about one to five days, and is self-limiting, but if it is severe or associated with risk, treatment with neuroleptic medication may be indicated.

It is important for the caregivers to have an understanding of the different types of seizure that can occur. They should be provided with written information and given the opportunity to discuss this with a doctor or a specialist nurse. This also assists in seizure recording by the caregiver, which can be invaluable in the overall, longer-term management of the patient.

If a seizure exacerbation occurs in established epilepsy, then it is again necessary to try to discover whether there is an identifiable precipitant such as an intercurrent illness, failure to take the medication, or disturbed sleep pattern. Other precipitants may be responsible in particular individuals. Sometimes the pattern of the epilepsy involves having clusters of seizures, when several seizures occur over one day or over a few days. If the individual is known to have clusters of seizures, the prescription of an oral benzodiazepine such as clobazam after the second seizure of the cluster can be helpful. If the person always has clusters of seizures, then the oral benzodiazepine may be given after the first seizure (of the anticipated cluster). If giving a single dose is not effective, it may be worth considering giving the oral benzodiazepine over the expected period of the cluster. This reduces the number of seizures in at least some people. In others it appears only to delay the cluster.

In this context it is worth mentioning that some females have seizure exacerbations around the time of their menstrual period.7,8 If this pattern is well established, giving an oral benzodiazepine such as clobazam for a few days at the right time in the menstrual cycle may greatly decrease the number of seizures or may even eliminate them altogether.

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