A Textbook of Clinical Pharmacology and Therapeutics

140 ANTI-EPILEPTICS

dose should be reduced gradually (e.g. over six months or
more) with strict instructions to report any seizure activity.
Patients should not drive during withdrawal or for six months
afterwards.

FEBRILE CONVULSIONS

Febrile seizures are the most common seizures of childhood. A
febrile convulsion is defined as a convulsion that occurs in a

child aged between three months and five years with a fever,

but without any other evident cause, such as an intracranial

infection or previous non-febrile convulsions. Approximately

3% of children have at least one febrile convulsion, of whom

about one-third will have one or more recurrences and 3% will

develop epilepsy in later life.

Despite the usually insignificant medical consequences, a

febrile convulsion is a terrifying experience to parents. Most

children are admitted to hospital following their first febrile

convulsion. If prolonged, the convulsion can be terminated

with either rectal or intravenous (formulated as an emulsion)

diazepam. If the child is under 18 months old, pyogenic

meningitis should be excluded. It is usual to reduce fever by

givingparacetamol, removal of clothing, tepid sponging and

fanning. Fever is usually due to viral infection, but if a bacter-

ial cause is found this should be treated.

Uncomplicated febrile seizures have an excellent progno-

sis, so the parents can be confidently reassured. They should

be advised how to reduce the fever and how to deal with a

subsequent fit, should this occur. There is no evidence that

prophylactic drugs reduce the likelihood of developing

epilepsy in later life, and any benefits are outweighed by

adverse effects. Rectal diazepammay be administered by par-

ents as prophylaxis during a febrile illness, or to stop a pro-

longed convulsion.

Maintain airway and breathing,

remove obstructions to breathing

i.v. or p.r. benzodiazepine

(e.g. diazepam)

Continued fitting?

Yes No

No

i.v. phenytoin infusion

(with ECG monitoring)

Monitor for breathing,

haemodynamic status

repeat seizure activity

Continued fitting?
Yes
Treat in
intensive care unit with
continuous ECG monitoring

i.v. clomethiazole or

phenobarbital

General anaesthesia

if necessary

(e.g. i.v. thiopental)

± paralysing agent

and assisted ventilation

Recommence/increase oral

anti-epileptics, treat any

precipitants

• alcohol


• hypoglycaemia


• drugs


• poor adherence


• infection


• other

Figure 22.3:Management of status epilepticus.

Table 22.3:Driving and epilepsy

Patients with epilepsy may drive a motor vehicle (but not an

HGVaor public service vehicle) provided that they have been

seizure free for one year or have established a three-year

period of seizures whilst asleep.

Patients affected by drowsiness should not drive or operate

machinery.

Patients should not drive during withdrawal of anticonvulsants

or for six months thereafter.

aAn HGV licence can be held by a person who has been seizure free and
off all anticonvulsant medication for ten years or longer.