1. Base Course Epilepsy/Seizures mhGAP-IG base course - field test version 1.00 – May 2012 1 Field test version-1.00May 2012 DO NOT UPLOAD ON THE INTERNET

2. mhGAP-IG base course - field test version 1.00 – May 2012 2 Contents (Epilepsy/Seizures) A.Introduction 25 minutes B.Learning objectives C.Emergency management of seizures 70 min D.Key actions 1.Establish communication and build trust 5 min 2.Conduct assessment 30 min 3.Plan and start management 80 min 4.Link with other services and supports 5 min 5.Follow up 25 min Total time: 4 hours

3. mhGAP-IG base course - field test version 1.00 – May 2012 3 Share your experience Has anyone of you witnessed a seizure? What did you see? This course will only cover (generalized) convulsive seizures Generalized seizures account for 70% of all seizures

4. mhGAP-IG base course - field test version 1.00 – May 2012 4 TRUE or FALSE Seizures are contagious FALSE Epilepsy is caused by witchcraft, possession, or evil spirits FALSE Seizures are abnormal electrical discharges from neurons TRUE People with epilepsy should be restrained FALSE Children of people with epilepsy will develop epilepsy as well FALSE People with epilepsy can be treated by primary health care doctors and nurses TRUE With antiepileptic medicines 70% can be seizure-free when treated in primary health care

5. mhGAP-IG base course - field test version 1.00 – May 2012 5 What do local people believe? What causes seizures or epilepsy? What is the treatment for seizures or epilepsy?

6. mhGAP-IG base course - field test version 1.00 – May 2012 6 What are seizures? Seizures are episodes of brain malfunction due to abnormal electrical discharges –Seizures can be classified as generalized or partial according to the clinical presentation –We will only discuss generalized seizures today Seizures can cause –Loss of consciousness –Convulsive movements (i.e. involuntary shaking of body) –Incontinence of urine or stool –Tongue biting

7. Generalized Tonic Clonic Seizure mhGAP-IG base course - field test version 1.00 – May 2012 7

8. 8 What is epilepsy? The condition in which people experience recurrent (at least twice), unprovoked seizures –Recurrent = usually separated by days, weeks or months –Unprovoked = there is no evidence of an acute cause of the seizure (e.g. febrile seizure in a young child)

9. mhGAP-IG base course - field test version 1.00 – May 2012 9 What causes epilepsy? Complications during childbirth Head injury Brain infections – Meningitis, encephalitis, cerebral malaria Neurocysticercosis (tape worm) Genetic, only in some cases Some epilepsy has no known cause Stroke It is important to note that most epilepsy is not inherited! People with epilepsy only rarely have children with epilepsy

10. mhGAP-IG base course - field test version 1.00 – May 2012 10 Contents (Epilepsy/Seizures) A.Introduction B.Learning objectives C.Emergency management of seizures D.Key actions 1.Establish communication and build trust 2.Conduct assessment 3.Plan and start management 4.Link with other services and supports 5.Follow up 10

11. mhGAP-IG base course - field test version 1.00 – May 2012 11 Learning objectives To be able to assess and manage an acute seizure To be able to use the master chart to suspect epilepsy To be able to assess a person with epilepsy To be able to prescribe and monitor antiepileptic medication To be able to educate people about their condition and its treatment To be able to follow up appropriately To be able to understand when it is necessary to refer to a specialist 11

12. mhGAP-IG base course - field test version 1.00 – May 2012 12 Contents (Epilepsy/Seizures) A.Introduction B.Learning objectives C.Emergency management of seizures D. Key actions 1.Establish communication and build trust 2.Conduct assessment 3.Plan and start management 4.Link with other services and supports 5.Follow up 12

13. mhGAP-IG base course - field test version 1.00 – May 2012 13 What do you need for management of an acute seizure? Equipment Light Source for checking pupils IV Canula and givingset 1 Syringes Needles appropriate for deep IM injections Materials for stabilizing the neck in case of trauma (can be made locally) Blood pressure cuff Stethoscope Thermometer Glucometer or other ability to measure serum glucose Medications 50% glucose IV fluid Diazepam/Lorazepam for IV delivery Oxygen and tubing for delivery via facemask 2 Phenobarbital and/or Phenytoin for IV delivery Special situation Magnesium sulfate for IM delivery 2% Lignocaine Hydralazine for IV delivery Antibiotics/Antimalarials

14. mhGAP-IG base course - field test version 1.00 – May 2012 14 Why is management of seizures an emergency? Prolonged or repeated seizures can result in brain injury Prolonged or repeated seizures can result in death if not treated immediately Seizures can be a symptom of a life-threatening problem, like meningitis Treatment can end seizures or shorten seizure duration

15. mhGAP-IG base course - field test version 1.00 – May 2012 15 Case Study: Group discussion A person is brought into the clinic, and is unconscious after a reported seizure… What are always your first actions CABs Check for good pulses and circulation Check airway Ensure breathing

16. mhGAP-IG base course - field test version 1.00 – May 2012 16 Using the mhGAP-IG for acute seizures We will now use the mhGAP-IG to assess and manage our case study Open the mhGAP-IG p 32

17. mhGAP-IG base course - field test version 1.00 – May 2012 17

18. mhGAP-IG base course - field test version 1.00 – May 2012 18

19. mhGAP-IG base course - field test version 1.00 – May 2012 19 First action in All Cases: Check C-A-B 1.Circulation 2.Airway 3.Breathing DO NOT leave the person alone Place in recovery position Make sure NOTHING is in the mouth

20. mhGAP-IG base course - field test version 1.00 – May 2012 20 If the person is still unconscious, use the recovery position

21. mhGAP-IG base course - field test version 1.00 – May 2012 21 Measure and document vital signs 1.Blood Pressure 2.Temperature 3.Respiratory rate These must be measured accurately and documented In particular, respiratory rate should be counted. You may be using drugs that cause respiratory depression

22. mhGAP-IG base course - field test version 1.00 – May 2012 22 What to look for on physical examination? Signs of head and/or spinal trauma Pupils: Dilated? Pinpoint? Unequal? Unreactive? Signs of meningitis: stiff neck, vomiting Weakness on one side of body or in one limb In unconscious people, who are unresponsive to pain, you may notice that one limb or side of the body is “floppy” compared to the other

23. mhGAP-IG base course - field test version 1.00 – May 2012 23 What should you ask? To assess severity: 1.If unconscious, ask an accompanying person: “Has there been a recent convulsion?” 2.How long was the impaired consciousness/convulsion? 3.How many episodes of convulsions were there? You also need to ask about: 1.Head trauma or neck injury 2.Fever, vomiting, headache (to assess for meningitis) 3.A history of epilepsy 4.Other medical problems (see next slide)

24. mhGAP-IG base course - field test version 1.00 – May 2012 24 Ask about other medical conditions 1.Are they diabetic? Are they on any medications?  Could this be low blood sugar? 2.Are they HIV-positive? Are they on any medication?  Could this be an infection (e.g. meningitis)? 3.Is there any chance of poisoning? 4.Is this person a drug user or a heavy drinker?  If yes, in addition to managing their acute seizures, you will need to do an assessment according to the Drug and Alcohol Use sections of the mhGAP-IG

25. mhGAP-IG base course - field test version 1.00 – May 2012 25 Case study continues The person starts to convulse again What are always your initial actions First action in all cases; CAB Circulation Airway Breathing

26. mhGAP-IG base course - field test version 1.00 – May 2012 26 Further management of acute seizure Start intravenous fluids IV Glucose slowly, 30 drops/minute Adults: Give IV Diazepam 10mg slowly OR IV Lorazepam 4mg slowly Children: Give diazepam IV 0.2 -0.5 mg/kg slowly (maximum 10 mg) or lorazepam IV 0.1 mg/kg(maximum 4mg), if available

27. mhGAP-IG base course - field test version 1.00 – May 2012 27 I cannot get the IV placed! What should I do? If you cannot place an intravenous cannula DO NOT GIVE IM DIAZEPAM, it is poorly and erratically absorbed Give rectal diazepam Use the rectal formulation if available If the rectal formulation is not available, the IV formulation can be used Adults: 10mg Children: 0.2 – 0.5 mg/kg (maximum 10mg) Do not forget to place an IV cannula after the seizure has stopped

28. mhGAP-IG base course - field test version 1.00 – May 2012 28 Rectal diazepam

29. mhGAP-IG base course - field test version 1.00 – May 2012 29 What if the seizure doesn't stop? It could be Status epilepticus Status epilepticus is defined as: 1. More than 30 minutes of continuous seizure activity OR 2. Two or more sequential seizures without full recovery of consciousness between seizures What would you do Use the mhGAP-IG to answer. If the seizure does not stop 10 minutes after the first dose of diazepam, give a second dose of the same amount Refer the person to hospital as this is an emergency Do not give more than 2 doses of diazepam

30. mhGAP-IG base course - field test version 1.00 – May 2012 30 What if you suspect a brain infection? If there are signs and symptoms (e.g. fever, vomiting, rash) 1.Manage the seizure as we have discussed 2.Initiate treatment for the underlying brain infection (such as IV antibiotic for meningitis) 3.Refer to hospital as this is an emergency

31. mhGAP-IG base course - field test version 1.00 – May 2012 31 What if you suspect trauma? 1.Manage the seizure as we have discussed 2.Stabilize the neck DO NOT move the neck There could be a cervical spine injury Log roll the person when moving 3.Assess for other evidence of trauma 4.Refer to the hospital as this is an emergency

32. mhGAP-IG base course - field test version 1.00 – May 2012 32 How to check for other evidence of trauma 1.Remove all clothing and check whole body for evidence of trauma 2.Look/feel for deformity of the skull 3.Check if pupils are not equal or not reactive to light 4.Check for blood/fluid from the ears or nose 5.Look for associated traumatic injuries (spine, chest, pelvis) From IMAI District Clinician Manual: Vol 1, Section 2 page 7

33. mhGAP-IG base course - field test version 1.00 – May 2012 33 What if the person is pregnant and has seizures? A pregnant woman who has no history of epilepsy and presents with seizure may have eclampsia Eclampsia is a condition in which one or more convulsions occur in a pregnant woman suffering from high blood pressure, The condition poses a threat to the health of mother and baby If there is a midwife in your clinic, call them to assist. They may have had training in how to manage eclampsia Refer to a hospital as this is an emergency

34. mhGAP-IG base course - field test version 1.00 – May 2012 34 What if the person is a child with fever? It could be a febrile seizure Febrile seizures are events occurring in children (3 months to 5 years of age) who are suffering from fever and don't have any neurological illness or brain infection Two types of Febrile Seizures 1.Complex, these need to be ruled out 2.Simple Febrile Seizures

35. mhGAP-IG base course - field test version 1.00 – May 2012 35 What is a complex febrile seizure? Please open the mhGAP-IG to page 34 and read the red box It is a complex febrile seizure if one of the criteria is present Focal – starts in one part of the body Prolonged – more than 15 minutes Repetitive – More then 1 episode during the current illness A complex febrile seizure needs to be referred to hospital

36. mhGAP-IG base course - field test version 1.00 – May 2012 36 Management of simple febrile seizures 1.Look for possible causes and manage fever according to the local IMCI guidelines 2.Observe for 24 hours 3.Follow-up in 1-2 months to assure no further seizures

37. mhGAP-IG base course - field test version 1.00 – May 2012 37 Summary for acute seizure management 1.Why is the management of seizures an emergency 1.Prolonged seizures can cause brain injury and death 2.Seizures can be a symptom of another disease (e.g. meningitis) 2.If a person presents convulsing in your clinic, what are the initial actions that you should take 1.ABC and positioning 2.Asses and manage simultaneously

38. mhGAP-IG base course - field test version 1.00 – May 2012 38 Key messages from acute seizure management Seizures are a symptoms not a cause, you need to look for a cause If the person presents convulsing it is an emergency and needs to be treated urgently a) seizures can a sign of a life-threatening problem b) seizures can result in brain injury or death! In persons who are having seizures, assessment and management should be done at the same time