IM20.3-5 | Seizure Disorder Management and Safety — Summary & Reflection

KEY TAKEAWAYS

Acute seizure management: Lateral recovery position, protect from injury, time the seizure, check glucose. Do not restrain or insert anything in mouth. Ambulance if >5 minutes (= status epilepticus threshold).

Status epilepticus stepwise protocol:
- 0–5 min: ABCs, glucose (thiamine before dextrose in malnourished/alcoholic), IV access, bloods
- 5–20 min: IV lorazepam 0.1 mg/kg (max 4 mg) or IM midazolam 10 mg; repeat once after 5 min
- 20–40 min: IV levetiracetam 60 mg/kg OR valproate 40 mg/kg OR phenytoin 20 mg/kg
- >40–60 min (refractory SE): ICU, intubation, EEG monitoring, propofol/midazolam/thiopental infusion

AED selection by seizure type:
- Focal epilepsy: carbamazepine, levetiracetam, lamotrigine, oxcarbazepine
- Generalised (GTCS, JME): sodium valproate (best efficacy but high teratogenicity), levetiracetam, lamotrigine; NEVER carbamazepine, phenytoin, gabapentin, pregabalin
- Typical absence only: ethosuximide first-line; NEVER carbamazepine or phenytoin
- Women of childbearing age: prefer levetiracetam or lamotrigine; valproate only with documented Pregnancy Prevention Programme

Drug interactions: Enzyme inducers (carbamazepine, phenytoin, phenobarbital) → OCP failure, warfarin under-anticoagulation. Valproate inhibits lamotrigine metabolism. Phenytoin = zero-order kinetics → toxicity: nystagmus → ataxia → encephalopathy.

Safety counselling: No driving until seizure-free ≥1 year (Motor Vehicles Act India); avoid heights, machinery, open water; no solo swimming; regular sleep; moderate alcohol only; AED adherence; valproate teratogenicity counselling and folic acid 5 mg/day pre-conception for all women on AEDs.

Drug-resistant epilepsy: Failure of 2 adequate AED trials → refer tertiary epilepsy centre (surgery evaluation for temporal lobe epilepsy — 60–70% seizure freedom with temporal lobectomy).

REFLECT

Return to the opening hook: the emergency scenario (12-minute status epilepticus, lorazepam already given without response) demanded immediate IV levetiracetam or valproate loading — not another benzodiazepine, not waiting. The safety counselling scenario demanded specific, documented answers about driving (not allowed until seizure-free ≥1 year), construction work at heights (not safe while seizures are active), and alcohol (moderate only, never binge, never drive after alcohol on AEDs). Reflect on this: of all the counselling domains covered in this module, which do you think is most likely to be inadequately communicated in a brief outpatient encounter — and why? And from the patient's perspective: how would you frame the conversation about not being able to drive in a way that acknowledges the real impact on their life while being clear about the legal and safety obligation? The technical knowledge and the communication skill are both required at the NMC SH level, and this reflection is an invitation to rehearse the latter.