Convulsions
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Appropriate assessment to identify cause and severity of symptoms
Explanation to patient and family
Consider disease-specific palliative therapy
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Consider adjuvant/second-line treatment
Prophylactic management of seizures
Review assessment and management
At all stages of management consider
Definition
An involuntary contraction of the muscles producing contortion of the body and limbs.
Appropriate assessment to identify cause and severity of symptoms
Assess the following:
- Duration and severity of the seizure.
- The circumstances before the seizure.
- Point of origin of seizure.
- The parts of the body that are involved.
- The type of movements in the part of the body involved in the seizure.
- Size of and changes in pupils.
- Presence of automatism.
- Changes in consciousness.
- Incontinence of urine or faeces.
- Any residual symptoms post seizure: paralysis or weakness, inability to speak, confusion, sleep, etc.
- Once seizure is over, monitor blood pressure, pulse, respiration and temperature.
- Take blood samples to eliminate metabolic disorder or chemical imbalance that may be causing the convulsions.
Explanation to patient and family
It is important to realise that seizures are very traumatic for the patient and the family. It is important to reassure them and to make the patient as comfortable as possible and maintain the patient’s dignity.
- Explain what is happening.
- Explain possible causes
- Explain immediate & long-term management.
Correct reversible factors
- Treat pyrexia if present.
- Treat any other conditions that may have caused seizures.
- If brain tumour is the cause, consider steroid therapy to reduce inflammation around it which may reduce seizures. Also consider palliative radiation and/or chemotherapy to shrink the tumour so as to reduce seizures.
Consider disease-specific palliative therapy
If the patient’s condition is imminently terminal, sedation may be appropriate to reduce distress and discomfort.
Institute non-pharmacological interventions
- Clear airway
- Put patient into the recovery position & secure the environment to prevent injury.
Prescribe appropriate first-line treatment
Give appropriate medications:
- Diazepam 10mg PR (repeat after 15 and 30 min PRN)
OR
- Lorazepam 2-4mg SL, SC or IV (repeat after 15 & 30 min PRN)
OR
- Midazolam 5-10mg SC or IV (repeat after 15 min PRN)
Consider adjuvant/second-line treatment
- Consider doubling the dose of diazepam or midazolam
OR
- Phenobarbital 100-200mg SC or IV (slowly by IV over 30 min with 100cc of saline) Repeat PRN. Follow with 100mg TDS SC.
Prophylactic management of seizures
Seizure prophylaxis with anticonvulsants has only been proven useful in patients with brain metastasis due to malignant melanoma & in patients with brain metastases from other cancers who have already had a seizure.
- Anticonvulsants:
- Phenytoin 300mg PO followed by 100-200mg PO TDS
- Carbamazapine 100mg PO BD
- Valproate 200mg PO BD
- Other anticonvulsants appropriate to the situation may also be used.
- Drug interactions! Be mindful of possible drug interactions with existing medication regimes.
- Corticosteroids are helpful in the prevention and management of seizures which are secondary to brain metastases, by decreasing the oedema surrounding the tumour mass. Be mindful & monitor the dose and duration of treatment, especially when used for more than 4 weeks.
- Radiation can be helpful in preventing seizures in patients with metastatic brain disease.
- Opioid rotation: Opioids rarely cause seizures, but some are known to do so; switching to another opioid can be helpful.
Review assessment and management
Regular assessment of treatment and management is necessary to ensure optimal management.
At all stages of management consider
Involvement of interdisciplinary team
As with all palliative care issues; the management of the patient who is experiencing seizures is best accomplished by an interdisciplinary team approach. The physical, psychosocial and spiritual components of care all need to be addressed. The doctor, pharmacist, nurse, social worker and/or psychologist and the spiritual practitioner all need to be involved, and if residual physical or neurological symptoms persist, an occupational or physiotherapist will also be needed.
Referral to appropriate service/more experienced clinician
Depending on the patient’s wishes and the stage of disease, it may be appropriate to refer the patient to a neurologist for further investigation and management.