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16 Table 2: Prognostic index for recurrence of seizures after remission of epilepsy for patients taking only one antiepileptic drug (AED) Risk of seizure recurrence by two years (%) Period free from seizures 2 years Seizure history* TC My Oth 4 years TC My Oth 6 years TC My Oth 8 years TC My Oth years TC My Oth years TC My Oth Seizures after start of AED therapy Current EEG unavailable 60 Current EEG abnormal top figure=patient continues with AED bottom figure=slow withdrawal of AED Current EEG normal 55 No seizures after start of AED therapy Current EEG unavailable Current EEG abnormal Current EEG normal *TC: history of idiopathic or secondary generalised tonic-clonic seizures My: history of myoclonic seizures with tonic-clonic seizures (myoclonic seizures rarely occur alone) Oth: history of seizures other than tonic-clonic or myoclonic

17 Table 3: Prognostic index for recurrence of seizures after remission of epilepsy for patients taking more than one antiepileptic drug (AED) Risk of seizure recurrence by two years (%) Period free from seizures 2 years Seizure history* TC My Oth 4 years TC My Oth 6 years TC My Oth 8 years TC My Oth years TC My Oth years TC My Oth Seizures after start of AED therapy Current EEG unavailable Current EEG abnormal top figure=patient continues with AED bottom figure=slow withdrawal of AED Current EEG normal No seizures after start of AED therapy Current EEG unavailable Current EEG abnormal Current EEG normal *TC: history of idiopathic or secondary generalised tonic-clonic seizures My: history of myoclonic seizures with tonic-clonic seizures (myoclonic seizures rarely occur alone) Oth: history of seizures other than tonic-clonic or myoclonic

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19 3 TREATMENT often be attributed to inadequate or delayed treatment Other types of status epilepticus (including simple partial, complex partial and absence status epilepticus) are often associated with delayed diagnosis and treatment, but have a much lower risk of morbidity. Prompt and accurate differentiation of status epilepticus from pseudo-status epilepticus and other non-epileptic disorders is crucial if inappropriate treatment and iatrogenic morbidity are to be avoided. 168,171 EEG recording may be necessary to confirm the diagnosis and to assess control, when seizures are clinically subtle (eg in partial status, or following treatment of tonic-clonic status epilepticus) GENERALISED TONIC-CLONIC STATUS EPILEPTICUS Recommendations for treatment are based on two large prospective, randomised trials of the management of status epilepticus 173,174 and on small or uncontrolled studies, physiological principles and pharmacokinetic considerations. 167, Intravenous lorazepam and diazepam are both effective and safe in controlling tonic-clonic status epilepticus, when administered by paramedics, prior to transport to hospital, with a trend in favour of lorazepam. 173 Intravenous lorazepam, phenobarbital and diazepam plus phenytoin are all effective initial treatments on hospital admission, with a trend again in favour of lorazepam, which is significantly more effective than phenytoin alone. 174 Lorazepam has the advantage over diazepam of a much longer duration of action, but its use in the community is limited by the need for refrigerated storage. There should be a high level of awareness of the risk of respiratory depression. Additional maintenance treatment is required following initial use of either benzodiazepine. Fosphenytoin is less irritant to veins than phenytoin and can be administered more rapidly (but still needs to be given slowly) IMMEDIATE MEASURES D A D In the community or in hospital, patients with generalised tonic-clonic status epilepticus should be managed immediately as follows (with local protocols being in place): n n n n secure airway give oxygen assess cardiac and respiratory function secure IV access in large veins. Give lorazepam 4mg IV or diazepam mg IV if lorazepam is unavailable. This can be repeated in hospital after minutes if there is no response. If there is a delay in gaining IV access in the community: give diazepam -mg rectally (rectal solution or IV solution). In hospital: n n n collect blood for full blood count, urea and electrolyte, liver function tests, calcium, glucose, clotting, AED levels and storage for later analyses measure blood gases to assess extent of acidosis establish aetiology. Give 50ml 50% glucose IV if there is any suggestion of hypoglycaemia and IV thiamine (given as Pabrinex two pairs of ampoules) if there is any suggestion of alcohol abuse or impaired nutritional status. WITHIN MINUTES D B For sustained control in patients with established epilepsy, within minutes: n give usual AED treatment orally or by nasogastric tube (or IV if necessary for phenytoin, sodium valproate and phenobarbital). For sustained control in other patients or if seizures continue, within minutes: n give fosphenytoin in a dose of 18mg/kg phenytoin equivalent (PE) IV, up to 0mg/ min with ECG monitoring; or phenytoin 18mg/kg IV, 50mg/min with ECG monitoring or phenobarbital mg/kg IV, 0mg/min. Rates of infusion may need to be reduced if hypotension or arrythmia occur or in elderley or renal/ hepatic impairment. þ Clear policies should be in place to avoid confusion between doses, formulations, routes and rates of administration of fosphenytoin and phenytoin. 17

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44 Secure diagnosis of first unprovoked tonic-clonic seizure Previous myoclonic / absence / partial/ complex partial seizures? NO Does patient consider risk of recurrence (and consequences), unacceptable and will s/he take AED therapy? * YES YES Treat after first tonic-clonic seizure NO Defer treatment 66 * Risk of recurrence overall risk -% risk highest soon after first seizure: up to 80% after one week >80% risk if EEG shows epileptic discharges >90% risk if patient has tumour/neurological deficit from birth <% risk if seizures are acute symptomatic Risk of recurrent epileptic seizures sudden unexplained death accidents extended driving licence withdrawal Risk of AED therapy side effects - minor -%, life-threatening very rare drug interactions eg oral contraceptive, with enzyme-inducing AEDs teratogenesis (4-6% major malformation with one AED)

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