How are seizures related to glucose levels managed?

Management of Seizures Related to Glucose Levels

For seizures related to glucose abnormalities, immediate assessment of blood glucose and appropriate treatment of the underlying glucose disturbance is essential, with hypoglycemia requiring rapid glucose administration and hyperglycemia requiring insulin and rehydration.

Hypoglycemia-Related Seizures

Recognition and Assessment

• Hypoglycemia is a known cause of seizures, particularly in patients with diabetes on insulin or sulfonylureas 1
• Severe hypoglycemia (blood glucose <54 mg/dL or Level 2) can cause seizures, altered mental status, and loss of consciousness 2
• Hypoglycemia should be suspected in any patient with seizures, especially those with:
  • Known diabetes on insulin or sulfonylureas
  • History of recurrent hypoglycemia
  • No prior history of epilepsy

Immediate Management

1. For conscious patients able to swallow:

   • Administer 15-20g of oral glucose 1, 2
   • Options include glucose tablets, juice (6-8 oz), regular soda, or 1 tablespoon of honey/table sugar 2
   • Recheck blood glucose after 15 minutes; repeat treatment if still low 1
   • Once glucose normalizes, provide a protein-containing snack to prevent recurrence 2

2. For unconscious patients or those unable to swallow:

   • Activate emergency medical services immediately 1
   • Administer glucagon if available:
     • Adults: 1mg IM/SC 3
     • Children: 0.03 mg/kg up to 1mg maximum 2
   • If IV access is available, administer IV glucose:
     • Adults: 20-40ml of 50% glucose solution 2, 3
     • Children: 0.5-1.0 g/kg of dextrose (avoid D50W in children; use D25W or D10W) 2
   • Monitor for recurrent hypoglycemia as it may occur after apparent clinical recovery 3

Prevention of Recurrence

• After a severe hypoglycemic seizure, temporarily raise glycemic targets for several weeks to restore hypoglycemia awareness and reduce future episodes 1, 2
• Prescribe glucagon for all patients at risk of severe hypoglycemia 1
• Educate patients, family members, and caregivers on glucagon administration 1
• Consider continuous glucose monitoring for high-risk patients 2

Hyperglycemia-Related Seizures

Recognition and Assessment

• Severe hyperglycemia, particularly non-ketotic hyperglycemia, can also trigger seizures 4, 5
• Hyperglycemic seizures often present as focal seizures and may be resistant to anticonvulsant medications 5
• Research shows that poor glycemic control (HbA1c >9%) is associated with higher risk of seizure recurrence (44.8% vs. 8.3%) and seizure clustering (79.3% vs. 25%) 4

Management

• Treat the underlying hyperglycemia with insulin and rehydration 5
• Monitor for signs of diabetic ketoacidosis (DKA), which requires immediate medical attention 1
• Anticonvulsant medications alone are often ineffective; glucose normalization is essential 5
• For patients with recurrent seizures due to hyperglycemia, aggressive blood sugar control is crucial 4

Special Considerations

Emergency Department Approach

• In the emergency department, approximately 5% of patients with hypoglycemia may present with seizures 6
• The initial blood glucose levels between hypoglycemic patients with and without seizures are not significantly different 6
• For patients with seizures of unknown etiology, check blood glucose promptly but do not delay anticonvulsant treatment 7

Prehospital Care

• Studies show that hypoglycemia is rare (1.2%) among prehospital seizure patients 7
• For actively seizing patients, administering benzodiazepines should not be delayed for glucose testing 7
• For pediatric seizure patients, universal blood glucose testing has low utility as hypoglycemia is extremely rare (0.5%) 8

When to Activate Emergency Services

• Activate emergency services for seizures related to glucose abnormalities in the following situations 1:
  • First-time seizure
  • Seizure lasting >5 minutes
  • Patient does not return to baseline within 5-10 minutes
  • Hypoglycemia with inability to swallow
  • Multiple seizures without return to baseline between episodes
  • Seizure with traumatic injury
  • Seizure occurring in water

Prevention Strategies

• For patients with diabetes at risk for hypoglycemia-induced seizures:

  • Ensure consistent carbohydrate content at meals 1
  • Educate about times of increased hypoglycemia risk (fasting, delayed meals, exercise, sleep) 1
  • Identify patients at greater risk (those on insulin or sulfonylureas, history of severe hypoglycemia) 1
  • Consider relaxing glycemic targets temporarily after severe episodes 2

• For patients with hyperglycemia-induced seizures:

  • Maintain tight glycemic control, especially in those with HbA1c >9% 4
  • Regular monitoring of blood glucose levels
  • Prompt treatment of hyperglycemic episodes

By addressing the underlying glucose abnormality and providing appropriate seizure management, most glucose-related seizures can be effectively controlled and prevented.