Second Seizure: Summary and Precautions

by Roy Strowd, MD

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    00:01 So in summary, the diagnostic investigation of a patient with a first time seizure is focused on figuring out the risk of a second seizure event.

    00:09 What is the risk of a second seizure? At 3 years in general, the risk is 40%.

    00:15 And we're using our findings on history, physical examination, EEG and MRI to determine whether that risk is higher than 40% or lower than 40%.

    00:26 Risk of a seizure with early and late treatment is still around 76 to 77%.

    00:31 So regardless of whether we initiate early treatment or not, the risk of a second seizure is about the same.

    00:38 And so typically, for a first time seizure, we would not initiate treatment.

    00:42 But there's some characteristics that raise our concern.

    00:46 So I'm going to walk through a table that can help us to see and understand these findings.

    00:51 What we're looking at here is the risk of a second seizure.

    00:54 And again, we said the risk of a second seizure in general is about 40%.

    00:59 If we look on history about whether the patient has a remote history of seizure.

    01:03 If there's no history of seizure, that risk stays at 40%.

    01:07 If the patient has a history of febrile seizures, or a post traumatic seizure many years ago, the risk goes up to 60%.

    01:14 And we'd be more concerned.

    01:16 When we think about the seizure type, a generalized seizure, the risk of second seizure is 40%.

    01:21 With a focal onset or partial onset seizure, that risk is higher at 60%.

    01:26 If the EEG is normal, our second seizure risk goes down to 26%, it's low.

    01:31 If abnormal, it's up to 56%.

    01:35 And if we think about the state of the patient seizures happening out of awakeness, that risk is low.

    01:40 But out of sleep, the risk of second seizure goes high.

    01:43 So again, we're using these findings to determine what the risk of a second seizure is, and that will be used to calibrate whether we want to start treatment or not.

    01:53 The last thing we think about when evaluating patients with the first time seizure is counselling.

    01:58 And really counselling for the event if a second seizure were to occur.

    02:02 We think about seizure precautions, what patients should do and not do given the risk of a potential seizure.

    02:08 Seizure, first aid what a caregiver should do at the time of a second seizure, and in general patient education.

    02:15 So how dangerous is a seizure? Seizures actually aren't life threatening in most situations.

    02:21 In terms of the primary risk of the seizure, brain injury is unlikely unless there's very prolonged tonic-clonic activity or severe status epilepticus.

    02:31 Ictal apnea can occur, but it's very rare except in neonates and so patients usually don't stop breathing during a seizure.

    02:39 SUDEP which is sudden unexplained death and epilepsy is a risk, and that's the one life threatening risk in epilepsy.

    02:48 We don't know why patients die in some situations with epilepsy.

    02:52 That's why it's sudden unexplained death in epilepsy.

    02:56 This tends to be more common or more commonly occur in patients with refractory epilepsy that occur frequently at night.

    03:02 But in general, the risk of dying during a seizure is very low.

    03:07 There are potential secondary risks.

    03:09 When patients are bathing or swimming, a seizure could cause them to drown or patients could drown during their seizure.

    03:16 When driving patients could suffer from an accident.

    03:19 And then there are various activities where we would be concerned if the patient lost consciousness that could lead to injury.

    03:25 And so when thinking about seizure precautions, we counselled them not to take bus unattended or swim unattended.

    03:32 Patients are not allowed to drive and there's varying rules and regulations about when patients can go back to driving after a seizure.

    03:38 And various activities where if the patient were to lose consciousness or have altered awareness, we would counsel against those.

    03:46 In terms of seizures at home, we counsel patients on first aid what to do if a seizure happens.

    03:51 Patient should be placed in a safe position, typically on their lateral side, laying on their side.

    03:58 Patients and caregivers or caregivers should clear everything out away from the patient so they can't hurt themselves during the event.

    04:05 We ask family members not to restrain movements or restrain patients and not to stick anything into a patient's mouth.

    04:11 Patients may bite their tongue, they won't bite their tongue off.

    04:14 And with anything in their mouth that won't prevent the tongue biting just put them at risk for having an injury from that being in their mouth.

    04:21 And we ask family members to stay away from the patient, and about 90 to 95% of seizures will resolve spontaneously within 1-3 minutes.

    04:30 For patients with a first time seizure who suffer a second seizure, we would typically ask for the patient to come in for emergent evaluation.

    04:38 To evaluate what may be causing that and to initiate treatment.

    04:42 For patients with refractory epilepsy that have frequent seizures.

    04:45 Many stay at home during or after a seizure and can be managed over the phone or in the clinic for further evaluation of their epilepsy.

    About the Lecture

    The lecture Second Seizure: Summary and Precautions by Roy Strowd, MD is from the course Seizures and Epilepsy.

    Included Quiz Questions

    1. Dangers associated with swimming and driving.
    2. Brain injury often being a direct result of a seizure.
    3. Placing a spoon in the mouth to prevent tongue biting during seizures.
    4. Restraint during seizures in preventing bodily injury.
    5. Immediate placement in a supine position during seizures.

    Author of lecture Second Seizure: Summary and Precautions

     Roy Strowd, MD

    Roy Strowd, MD

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