What is the treatment for convulsions (seizures) in a patient with malaria?

Treatment for Convulsions in Malaria

For convulsions in patients with malaria, administer paraldehyde 0.2 mL/kg IM for initial seizure control, followed by phenobarbital 10 mg/kg IM if convulsions persist. 1

Initial Management of Seizures in Malaria

Emergency Assessment

1. Position patient in left lateral position
2. Check blood glucose immediately (hypoglycemia may precipitate seizures) 1
3. Ensure adequate airway management and provide oxygen if hypoxic 1
4. Monitor for subtle seizures (eye deviation, irregular respiratory pattern, drooling) 1

First-Line Anticonvulsant Therapy

• For initial convulsion:

  • Administer paraldehyde 0.2 mL/kg IM 1
  • If convulsions recur, repeat the paraldehyde dose 1

• For persistent convulsions:

  • Administer phenobarbital 10 mg/kg IM 1
  • Alternative in hospital setting: Follow APLS seizure management algorithm with lorazepam 0.1 mg/kg IV/IO 1

Comprehensive Management Approach

Diagnostic Considerations

• In children with altered consciousness or repeated convulsions:
  • Perform lumbar puncture if possible to rule out meningitis 1
  • If CSF is cloudy, treat for meningitis and discontinue antimalarial treatment 1
  • If lumbar puncture cannot be performed, treat for both meningitis and malaria 1

Antimalarial Treatment

• If patient can swallow:

  • Administer appropriate oral antimalarial (sulfadoxine-pyrimethamine or artemisinin-based combination) 1, 2

• If patient cannot swallow or has persistent vomiting:

  • Administer IV quinine: Loading dose 20 mg/kg over 4 hours, then 10 mg/kg every 8-12 hours 1
  • For severe malaria: IV artesunate is now first-line therapy (20 mg/kg) 2, 3

Management of Complications

• Hypoglycemia prevention and treatment:

  • Use 5% dextrose with 1/2 normal saline for IV fluids 1
  • For confirmed hypoglycemia: Administer 50 mL of 50% IV dextrose 1

• Fluid management:

  • Exercise caution with fluid administration to prevent pulmonary edema and cerebral edema 1
  • Maintain cardiac output and renal perfusion while avoiding fluid overload 1

Special Considerations

Seizure Prophylaxis

• Prophylactic anticonvulsants are generally not recommended in modern settings 1
• However, a single dose of phenobarbital (3.5 mg/kg IM) has been shown to reduce subsequent convulsions from 54% to 12.5% in cerebral malaria 4

Route of Administration

• IV administration of anticonvulsants provides more reliable plasma concentrations than rectal administration 5
• If IV access is unavailable, rectal diazepam (0.5 mg/kg) can be used, though it has more variable absorption 5

Monitoring

• Close monitoring for recurrent seizures is essential as many patients (especially with IV diazepam) may experience seizure recurrence 5
• Monitor for signs of raised intracranial pressure, which may complicate cerebral malaria 1

Pitfalls to Avoid

1. Failing to recognize subtle seizures that present as eye deviation or irregular breathing patterns 1, 6
2. Delaying treatment of convulsions lasting more than 5 minutes (associated with neurological deficits) 6
3. Overlooking hypoglycemia as a cause or complication of seizures 1
4. Using mefloquine in patients with seizures (may lower seizure threshold) 7
5. Administering steroids (adverse effect on outcome in cerebral malaria) 1

Remember that severe malaria with convulsions is a medical emergency requiring prompt intervention to reduce morbidity and mortality.