What are seizure emergencies?
Most seizures last less than one or two minutes and stop on their own. Although many people with epilepsy have good seizure control, one in three people with epilepsy do not, and they continue to have seizures. Some people only have occasional seizures, but others may have frequent seizures.
There are a small group of people with epilepsy who have severe or even life-threatening seizures. These seizures are considered an emergency because they can be longer than usual (prolonged seizures) or happen in short succession one after the other (cluster seizures) with little or no recovery in-between. Both of these situations can lead to a medical state called status epilepticus. All these situations are considered seizure emergencies and can lead to brain injury or even death if not treated quickly.
What is status epilepticus?
Status epilepticus (SE) is a prolonged or continuous seizure lasting longer than 5 minutes or seizure clusters (seizures occurring repeatedly) without full recovery in-between.
Although any seizure type, convulsive or non-convulsive, can become status epilepticus, the convulsive (tonic-clonic) seizures are the most serious form and pose a greater risk of complications.
Whatever the seizure type, SE is regarded as a medical emergency and can be life threatening or have long term consequences if it is not treated quickly. Studies show that it is unlikely that a prolonged or cluster seizures will stop after 5-10 minutes (without giving medication) and the best outcome is when an emergency seizure medication can be given as soon as possible.
The sooner medication is given, the more likely the seizures are to stop and the better the outcome is for the person. This is why some people have medication prescribed to be given by caregivers, outside the hospital setting, before an ambulance arrives.
Causes of Status Epilepticus [i]
SE can happen in people with and without epilepsy. Sometimes it is the first seizure the person has ever had, sometimes it is caused by a medical condition, or it may happen in someone with epilepsy or an epilepsy syndrome. Up to 5% of adults and 10-25% of children with epilepsy will have one episode of SE.
The main causes of SE are having epilepsy, febrile seizures, and stroke but there are many other causes, which include: [ii]
- Brain injury
- Low levels of anti-seizure medication or withdrawal or changes in anti-seizure medications
- Specific epilepsy syndromes
- Serious illness, infection or sepsis
- Disease – malaria, encephalitis, brain tumour, dementia
- Intoxication or alcohol withdrawal
- Unknown cause
Effects of Status Epilepticus
SE can happen with any seizure type, so it can be convulsive or non-convulsive. Symptoms will depend on the type of seizure and can range from appearing vague and confused (non-convulsive) to more serious muscle jerking (convulsive) and loss of consciousness.
Short term effects can cause bodily changes which worsen the longer the seizures continue. These include increased blood pressure and heart rate, irregular heartbeats, and changes in blood sugar levels.
The long-term effects of SE depend on the cause and how long the seizures continue. Seizures lasting longer than 60 minutes and are convulsive are linked with poorer outcomes. Some long-term effects of SE can include:
- Memory and learning difficulties
- Permanent damage to the brain
- Continuing seizures
Medications for seizures outside the hospital setting
Emergency seizure medications are prescribed for people who have had, or likely to have episodes of SE or prolonged or cluster seizures. These medications can be given in the community setting in an easy to administer route and work quickly with the intention to stop a seizure early to prevent complications before it progresses to SE.[iii]
Outside the hospital setting, the medication is given either by drops or spray in the nose (intranasal), or in-between the teeth and cheek (buccal). When given this way, it is absorbed into the bloodstream through the mucous membranes. Because of the ease of administration, they can be given by family or caregivers in the community.
These medications are usually benzodiazepines – a group of medications known as sedatives which have a calming effect on the brain. They are administered in a way that:
- is easy to do outside the hospital setting
- is easily absorbed through the mucous membranes
- works quickly
- is very effective
The aim of these medications for seizures, is to:
- stop prolonged or cluster seizures
- prevent SE
- protect the brain by shortening the seizure time
- protect quality of life by preventing potential damage to the brain
- reduce disruption to daily life and long stints in hospital.
In many situations, early treatment outside the hospital setting can stop the seizures and prevent the progression into SE and the need for lengthy hospitalisation. [iv]
The longer a seizure lasts, the harder it can be to stop. Since most seizure emergencies occur in the community, effective pre-hospital treatment relies on the use of fast absorbing and easy to administer drugs. Growing evidence supports the use of non-intravenous benzodiazepines in the out-of-the-hospital environment.
Emergency seizure medications are usually very effective, but if they don’t work and seizures continue or complications occur, then emergency medical treatment will be needed at hospital.
Having a plan for seizures and emergencies
There is often the need to have a more formalised plan in place if a seizure occurs outside the home environment such as at school or in the workplace. These are often referred to as seizure management plans (SMP).
A seizure management plan (SMP) is a document that provides essential information to anyone who may be able to assist someone having a seizure – whether that be family, friends, carers, teachers, colleagues or other involved professionals. It helps caregivers in all settings with quick access information about how to manage seizures and seizure emergencies, treatments, seizure first aid and safety specific to the person with epilepsy that they care for. This can help to lessen the impact of seizures on the person’s daily life and the risk of injury.
A seizure management plan is to ensure the right people know what to do when a seizure happens. They give everyone a clear direction and peace of mind.
When someone is likely to have prolonged or cluster seizures, they will also have an emergency medication order and plan to accompany the seizure management plan. Your treating specialist will write up the emergency medication order, but if you need either of these documents – seizure management plan or an emergency medication plan – we can assist with this and offer the necessary training to caregivers or staff.
If you want to learn more about seizure management planning, seizures, seizure emergencies or the administration of emergency medication for epilepsy, go to:
[i] Trinka, E., Cock, H., Hesdorffer, D., Rossetti, A.O., Scheffer, I.E., Shinnar, S., Shorvon, S. and Lowenstein, D.H. (2015), A definition and classification of status epilepticus – Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia, 56: 1515-1523. https://doi.org/10.1111/epi.13121
[ii] Sánchez, S., & Rincon, F. (2016). Status Epilepticus: Epidemiology and Public Health Needs. Journal of clinical medicine, 5(8), 71. https://doi.org/10.3390/jcm5080071
[iii] Fedak Romanowski, Erin M. et al.(2020) Seizure Rescue Medications for Out-Of-Hospital Use in Children
The Journal of Pediatrics, Volume 229, 19 – 25, Oct 2020 https://doi.org/10.1016/j.jpeds.2020.10.041
[iv] Arzimanoglou, A., Lagae, L., Cross, J.H. et al. (2014) The administration of rescue medication to children with prolonged acute convulsive seizures in a non-hospital setting: an exploratory survey of healthcare professionals’ perspectives. European Journal of Pediatrics 173, 773–779 (2014). https://doi.org/10.1007/s00431-013-2255-5
Shah, A., and Kelso, A. (2015) Treating status epilepticus in the community. Prescribing in practice. 5 September, pg 21-24. https://wchh.onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1380 Accessed June 2021