Hailey Tran
Seizure clusters, or acute repetitive seizures, are a rare condition that affects people with epilepsy. They are unpredictable and emotionally burdensome to patients and caregivers and require prompt treatment to prevent serious outcomes, including status epilepticus, which can be life-threatening. Status epilepticus occurs when a seizure lasts more than 5 minutes or when seizures occur very close together without the person regaining consciousness between them. To stop repetitive seizures in a hospital setting, doctors may administer rescue medications such as benzodiazepines, diazepam rectal gel, midazolam nasal spray, or diazepam nasal spray. These medications are typically given through an IV or injected into a muscle. If medications are unsuccessful, hospital staff may decide to put the patient into a coma to stop the seizures.
| Characteristics | Values |
|---|---|
| When to seek hospital treatment | If seizures last longer than 5 minutes, or occur very close together without the person regaining consciousness between them, seek emergency medical treatment in a hospital setting. |
| Hospital treatments | Rescue medications (e.g. benzodiazepines, diazepam rectal gel, midazolam nasal spray, antiseizure medications), oxygen, breathing support, IV fluids, EEG testing, intubation, treating underlying causes, supportive treatments. In extreme cases, the patient may be put into a coma to stop the seizures. |
| Side effects of rescue medications | Drowsiness, dizziness, headache, pain, nasal irritation, fatigue, watery eyes, odd taste, physical dependence, withdrawal reactions, delirium, paranoia, suicidal thoughts or actions, difficulty breathing, seizures, nervous system changes, depression, hallucinations, shaking, stomach and muscle cramps. |
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What You'll Learn
Recognising seizure clusters
While there is no single definition of seizure clusters, experts generally agree that having two to three seizures within 24 hours, with recovery periods in between, constitutes a cluster. However, it's important to note that seizure clusters can also occur within a few hours, with seizures happening very close together. Seizure clusters can be emotionally burdensome and stressful for both patients and caregivers, and they require prompt treatment to prevent serious outcomes.
People who have had a head injury, experience focal onset seizures (seizures that start on one side of the brain), or have refractory epilepsy are more likely to experience seizure clusters. Additionally, some studies show that almost 50% of people with epilepsy have had three or more seizures within a 24-hour period at least once. Recognising seizure triggers can also help predict and prevent some seizure clusters.
It is crucial to distinguish seizure clusters from status epilepticus, a medical emergency that occurs when a seizure lasts longer than 5 minutes or when seizures occur repeatedly without full recovery of consciousness between them. Status epilepticus can be life-threatening and requires immediate medical attention. Therefore, recognising seizure clusters and seeking early treatment can often prevent the need for hospitalisation and reduce the risk of progressing to status epilepticus.
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Rescue medications
The most commonly used rescue medications are benzodiazepines, which work by limiting electrical activity in neurons to stop seizures. They are usually injected directly into the body or administered through an intravenous (IV) line. Benzodiazepines can also be administered nasally or rectally, with the former being preferred in public settings. The nasal spray and gel forms of these medications are rapidly absorbed by the tissue in the nose, mouth, and rectum. While these medications are fast-acting and effective, they can have side effects such as drowsiness, dizziness, nasal irritation, fatigue, and headaches.
Diazepam and midazolam are two commonly used benzodiazepines. Midazolam nasal spray (Nayzilam) is a prescription medication for the short-term treatment of seizure clusters in patients 12 years and older. It is important to note that benzodiazepines can cause physical dependence and withdrawal reactions, especially with daily use. Serious side effects, including coma and death, have occurred in cases of benzodiazepine abuse or misuse. Therefore, it is crucial to follow the prescribed dosage and not share or misuse these medications.
In addition to benzodiazepines, other rescue medications can be administered through an IV to stop seizures. These medications work faster than other methods, but there is a risk of incomplete drug absorption or adverse reactions at the injection site. It is important to discuss an emergency plan for seizure clusters with a doctor to understand when and how to use rescue treatments effectively.
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Intubation
Status epilepticus is a neurological emergency that occurs when a seizure lasts more than 5 minutes or when seizures occur in close succession without the person regaining consciousness between them. It is a medical emergency that requires immediate treatment in a hospital setting, as it can be life-threatening.
Endotracheal intubation is often required during the management of refractory status epilepticus. It is facilitated by anesthetic medications and can be used to prevent hypoventilation or pulmonary aspiration. However, the benefit of endotracheal intubation in this context is unclear, as many patients who are unresponsive after a seizure will recover quickly without airway and ventilator support. There is also a risk of masking the clinical signs of recurrent seizures.
On the other hand, delaying intubation to trial an anti-epileptic medication may prolong the seizure and increase associated complications. Propofol is a potent anti-epileptic agent that is often used during rapid sequence intubation. When bolused, it usually breaks the seizure, and it can be rapidly titrated. However, it can cause hypotension, so it may not be safe for patients in severe shock.
The combination of ketamine and propofol ("ketofol") has been shown to be effective in patients with super-refractory status epilepticus. Ketamine inhibits excitatory neurotransmitters in the brain, while propofol stimulates inhibitory neurotransmitters, resulting in a profound decrease in brain activity.
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Treating underlying causes
Treating the underlying causes of repetitive seizures is an important aspect of managing this medical emergency. The first step is to identify the cause of the seizure, which can vary from person to person and may be due to an underlying medical condition such as epilepsy, brain infections, brain tumours, strokes, or encephalitis. Once the underlying cause is identified, targeted treatment can be initiated.
For instance, in the case of epilepsy, which affects about 1.2% of the population in the USA, seizure clusters or acute repetitive seizures can occur. These seizure clusters are rare and unpredictable, and they can be emotionally burdensome for patients and their caregivers. To treat these seizure clusters, benzodiazepines are often prescribed as a rescue medication. Benzodiazepines work by limiting electrical activity in neurons, thereby stopping seizures. They can be administered in various forms, including intravenous (IV) injections, nasal sprays, gels, and rectal gels, depending on the situation and patient preference.
It is important to note that benzodiazepines are not without risks and side effects. Serious side effects, including coma and death, have been reported in cases of benzodiazepine abuse or misuse. Additionally, benzodiazepines can cause physical dependence, and stopping them suddenly can lead to withdrawal reactions and serious side effects, including seizures, nervous system changes, and suicidal thoughts or actions. Therefore, it is crucial to follow the prescribed dosage and not to share or misuse these medications.
Additionally, treating underlying causes may involve addressing other conditions or circumstances that can provoke seizures. These include high fevers, alcohol or drug withdrawal, low blood sugar, strokes, tumours, and encephalitis. By managing these underlying factors, the frequency and severity of repetitive seizures can be reduced, improving the patient's overall condition and quality of life.
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Inducing a coma
In cases where anti-seizure medications or other treatments fail to stop the seizures, medical professionals may decide to induce a coma as a last resort to halt the seizure activity. This procedure is not taken lightly and is only considered when other treatments have proven ineffective.
The process of inducing a coma involves administering medications to slow down brain activity and suppress consciousness. This state of reduced brain function is intended to interrupt the seizure activity and give the patient's body a chance to recover. It is a temporary measure, and the patient will be closely monitored to ensure their safety.
While inducing a coma can be an effective way to stop repetitive seizures, it is not without risks. Coma induction can have serious side effects, and prolonged coma may carry additional complications. Therefore, it is a measure of last resort, used only when other treatments have been unsuccessful.
It is important to note that the decision to induce a coma is a complex medical determination made by a team of specialists. Each patient's situation is unique, and the medical team will consider various factors, including the patient's health history, the type of seizures, and potential risks, before deciding on the most appropriate course of action.
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Frequently asked questions
Some medications that can be used to stop repetitive seizures include:
- Benzodiazepines (Benzos)
- Antiseizure medications (ASMs)
- Diazepam rectal gel
- Midazolam nasal spray
- Diazepam nasal spray
- Intubation
- Oxygen and breathing support
- IV fluids
If you can recognize seizure clusters or acute repetitive seizures, they can often be treated outside of a hospital setting. Rescue medications can be administered to terminate a seizure cluster, and benzodiazepines are the cornerstone of rescue treatment. Some examples of rescue medications include:
- Diazepam rectal gel
- Midazolam nasal spray
- Diazepam nasal spray
Seizure clusters are acute episodes of increased repetitive seizures, irrespective of type or grouping, that differ from the person’s usual seizure pattern. They happen when you have multiple seizures in a short time period, closer together than is usual for you, and recover between seizures.
