Epileptic Seizures and Status Epilepticus in Adolescents (13-18 Years) and Adults
Description General measures Medicine treatment Referral DESCRIPTION Additional causes of epileptic seizures to consider in adolescents and adults are categorised below: Pregnancy related Infections Substances & poisoning - eclampsia (See Adult Hospital STGs and EML, Eclampsia ) - electrolyte abnormalities (e.g. in hyperemesis gravidarum) - stroke - reduced blood levels of antiseizure m
DESCRIPTION
Additional causes of epileptic seizures to consider in adolescents and adults are categorised below:
| Pregnancy related | Infections | Substances & poisoning |
|
- eclampsia (See Adult Hospital STGs and EML, Eclampsia) - electrolyte abnormalities (e.g. in hyperemesis gravidarum) - stroke - reduced blood levels of antiseizure medication |
- meningitis - encephalitis - brain abscess - neurocysticercosis |
- substance abuse (e.g. cocaine, amphetamines) - withdrawal syndromes (e.g., benzodiazepine, alcohol) - medicine toxicity and overdose (e.g., antiseizure medications, antidepressants, antipsychotics, isoniazid) - environmental toxins (e.g. pesticides) |
| Metabolic conditions | Systemic disorders | Primary cerebral causes |
|
- hypoglycaemia - hypocalcaemia - hypomagnesaemia - hyponatraemia - hypernatraemia |
- vasculitis - hypertensive encephalopathy - uraemia (renal failure) - hyperammonaemia (liver failure) |
- tumour - trauma - neurodegenerative conditions - idiopathic/unknown |
Special considerations
Adolescents and young adults:
- High risk for substance intoxication or withdrawal, and for traumatic brain injuries.
- Mental health conditions are common, and may present as ‘epilepsy imitators’ (see differentials of epileptic seizures above and https://www.epilepsydiagnosis.org/epilepsy-imitators.html).
- Idiopathic generalised epilepsies (including epilepsy with generalised tonic-clonic seizures, juvenile myoclonic epilepsy, juvenile absence epilepsy) may first present in this age group.
- High risk for poor adherence to ASMs and breakthrough seizures.
- Often require intensive individual and family counselling and support, with appropriate involvement of social welfare and education sectors.
Girls and women in child-bearing age group:
- Exclude pregnancy and pregnancy related complications.
- ASM concentrations may become sub-therapeutic in pregnant women with epilepsy, causing breakthrough seizures. An increase in ASM dose may be required during pregnancy (reduce dose after delivery). Where possible monitor.
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CAUTION Children born to women taking valproate are at significant risk of birth defects (11%) and persistent developmental disorders (40%). Valproate is contra-indicated and should be avoided in pregnancy and in adolescents and women of child-bearing potential. |
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People > 65 years of age:
- Common reversible conditions include metabolic abnormalities, medications, alcohol withdrawal.
- The risk of developing epilepsy increases with age. Epilepsy in this age group is commonly caused by stroke, brain tumours and dementias. Continued ASM may be advisable after a single seizure in these patients.
GENERAL MEASURES
On arrival/ while fitting:
- Ensure the environment is safe. Remove all sharp objects and hot liquids.
- Place the patient in a lateral position to prevent aspiration of secretions or vomitus, on the floor if necessary.
- Do not place anything (spoon or spatula, etc.) in the patient's mouth.
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- Obtain an eyewitness account of the seizure onset and any associated impaired consciousness. If seizure duration is ≥ 5 minutes, commence urgent medicine treatment for convulsive status epilepticus (refer to table below on medicine management and supportive care of status epilepticus in adolescents and adults).
- Ensure the airway is not obstructed and administer oxygen via face mask or nasal cannula to maintain SaO2 ≥ 95%.
- Intubation should be performed if airway, ventilation, or oxygenation cannot be maintained, or if seizure is prolonged.
- Examine for fever; dehydration; meningism; hypoglycaemia; evidence of toxin or poison ingestion; head, neck or other trauma; obvious focal neurology; and other possible causes of the seizure.
- Secure intravenous access.
- Monitor vital signs every 15 minutes.
- Keep nil per mouth.
- Ensure the family/caregiver/escort is attended to. Social worker or auxiliary staff member should obtain all contact details and provide counselling as needed.
Convulsive status epilepticus:
If the seizure does not resolve within 5 minutes of onset, commence urgent medicine treatment.
MEDICINE TREATMENT
The aim is to control the seizure within 30 minutes of its onset, prevent complications of status epilepticus with supportive care, and identify and correct underlying causes. Follow standard resuscitation protocols, such as the ABCDE approach.
Table 2: MEDICINE MANAGEMENT AND SUPPORTIVE CARE OF STATUS EPILEPTICUS IN ADOLESCENTS AND ADULTS
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After The Seizure
Post Ictal Phase:
- Keep nil per mouth and haemodynamically stable until patient has regained consciousness and is aware of themself and their surroundings.
- If there is agitation or disturbed behaviour, consider post-ictal delirium and manage as for delirium – see Delirium.
- Clarify the cause of the seizure and manage appropriately. Further investigations (e.g. lumbar puncture and neuroimaging) are driven by clinical signs and seizure onset (e.g. focal onset).
- If meningitis is suspected, commence antibiotic therapy urgently.
- Counsel the patient and their family regarding the cause of the seizure, management given and likely sequelae of the seizure. Offer only as much information as the family or patient is able to receive at that time.
- If reversible causes of the epileptic seizure have been addressed, wean and stop ASMs. Consider whether the person meets the criteria for a diagnosis of epilepsy that requires ongoing ASMs (see Epilepsy).
- On discharge, set up a follow-up appointment to reinforce the counselling messages.
Active follow up:
Wean any residual ASMs, unless ongoing maintenance treatment is indicated, or epilepsy has been diagnosed.
REFERRAL
- All patients with status epilepticus must be referred to hospital for continued acute management and evaluation of the cause.
- New focal seizures for neuroimaging.
- Suspected meningitis.
Follow up social worker or rehabilitation services required.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.0_26 May 2025
Chapter 15: Central Nervous System Conditions_15.5 Status Epilepticus_15.5.2. Epileptic Seizures and Status Epilepticus in Adolescents (13-18 Years) and Adults