Assessing and Managing Seizures

Many people who drink heavily present to services (such as hospital, paramedic) following a seizure, and can pose a diagnostic dilemma for clinicians. The diagnosis of alcohol withdrawal seizures is one of exclusion of other causes of seizures. If any of these features are present, alcohol withdrawal seizures should not be assumed: 

• clinical features or suspicion of other causes of seizures (such as head injury, metabolic, infectious, neoplastic, cerebrovascular disorders) 
• no previous seizure history 
• two or more seizures in succession 
• partial-onset (focal) seizures 
• seizure occurring >48 hours after the last drink 
• no recent heavy alcohol use or no other features of alcohol withdrawal 

The patient should be admitted to hospital, assessed and monitored for at least 24 hours. Investigations should be undertaken according to relevant local guidelines. 

Where the diagnosis of alcohol withdrawal seizures can be clearly established, the following management plan is recommended: 

• admission into a supervised withdrawal setting for at least 48 to 72 hours 
• regular monitoring, including vital signs, alcohol withdrawal scales and neurological observations 
• thiamine administration (parenterally, see below) commencing if feasible before glucose administration. 
• supportive management, including rehydration and nursing in a quiet environment away from excessive sensory stimuli  
• benzodiazepines are recommended to prevent further seizures:  
  • midazolam (2–10 mg intravenous infusion if parenteral treatment is required in an acute care setting) with close monitoring of response, airway and saturation. 
  • diazepam loading (orally, see above) for a stable patient  
  • lorazepam (1–2 mg oral) if the clinician is concerned about respiratory or neurological function. 

Carbamazepine effectively prevents seizures in alcohol dependent people, but it does not effectively prevent recurrent seizures or onset of alcohol withdrawal delirium, and is therefore not generally recommended.