Treatment Algorithm for Seizures

Harrison's Principles of Internal Medicine, 22e — Chapter 436

STEP 1 — IDENTIFY THE SEIZURE TYPE

Seizure Occurs
      │
      ├──► PROVOKED (acute symptomatic)?
      │         ├── Metabolic (electrolytes, glucose, Na⁺)
      │         ├── Drug-induced (bupropion, cocaine, etc.)
      │         └── Structural lesion (tumor, abscess, vascular malformation)
      │
      └──► UNPROVOKED / EPILEPTIC?
                ├── Focal (with/without impaired awareness)
                ├── Generalized-onset tonic-clonic (GOTC)
                ├── Typical absence
                └── Atypical absence / Myoclonic / Atonic

STEP 2 — TREAT UNDERLYING CAUSE FIRST

STEP 3 — WHEN TO START ANTISEIZURE DRUG (ASD)?

Single seizure ─────────────────────────────────────────────────────►  Do NOT routinely treat
      │
      ├─► PLUS any of the following risk factors? → TREAT
      │         • Prior brain insult (stroke, trauma)
      │         • EEG epileptiform abnormalities
      │         • Significant brain imaging abnormality
      │         • Nocturnal seizure
      │         • Identified epileptogenic lesion (tumor, infection, trauma)
      │
      └─► Driving / employment considerations also weigh in favor of treatment

Recurrent seizures of unknown/irreversible cause → ALWAYS TREAT

STEP 4 — SELECT THE DRUG BY SEIZURE TYPE

Table 436-8 (Harrison's): Drug Selection

Worldwide, older drugs (phenytoin, valproic acid, carbamazepine, phenobarbital, ethosuximide) remain first-line because they are equally effective and significantly less expensive. Newer drugs are adjuncts or alternatives.

STEP 5 — TITRATION PRINCIPLES

Start at LOWEST dose → titrate slowly (allow ≥5 half-lives between dose changes)
      │
      ├─► Serum drug levels: useful to establish dosing & check compliance
      │       — NOT the primary target; clinical response + side effects take priority
      │       — In low albumin (liver/renal disease): check FREE drug levels
      │
      └─► Minor side effects (sedation, dizziness, ataxia): usually resolve in days → continue

STEP 6 — INADEQUATE RESPONSE ON FIRST DRUG

Seizures persist at maximum tolerated dose?
      │
      ├─► Confirm: documented compliance (check drug level)
      │
      ├─► Switch to second drug:
      │       • Add second ASD → optimize second drug → slowly taper first drug
      │       • Goal: MONOTHERAPY whenever possible
      │
      └─► Still refractory? → POLYPHARMACY
              • ~50% of patients fail first drug
              • Patients with structural lesions or multiple seizure types
                most likely to need combination therapy

STEP 7 — REFRACTORY EPILEPSY (drug-resistant)

Failed ≥2 appropriate drugs at adequate doses?
      │
      ├─► Surgical evaluation: 
      │       • Resection of seizure focus (most effective for focal epilepsy)
      │       • Prerequisites: localizable focus on EEG/MRI; resectable region
      │
      ├─► Neuromodulation:
      │       • Vagus nerve stimulation (VNS)
      │       • Thalamic deep brain stimulation (DBS)
      │       • Responsive neurostimulation (RNS)
      │
      └─► Dietary therapy:
              • Ketogenic diet (especially in children)

STEP 8 — WHEN TO DISCONTINUE THERAPY?

1. Complete seizure control for 1–5 years
2. Single seizure type (generalized > focal prognosis)
3. Normal neurologic exam including intelligence
4. No family history of epilepsy
5. Normal EEG

SPECIAL SITUATIONS

STATUS EPILEPTICUS — EMERGENCY ALGORITHM

GCSE (Generalized Convulsive Status Epilepticus)
Definition: seizures > 5 minutes, or repetitive without recovery

┌─────────────────────────────────────────────┐
│  IMMEDIATE (0–5 min)                        │
│  • Airway / Breathing / Circulation         │
│  • IV access + labs (glucose, electrolytes, │
│    drug levels, toxicology, CBC, LFTs)      │
│  • Treat hypoglycemia if present            │
│  • Treat hyperthermia                       │
└─────────────┬───────────────────────────────┘
              │
              ▼
┌─────────────────────────────────────────────┐
│  PHASE 1 — Benzodiazepine (5–20 min)        │
│  • Lorazepam IV (first choice)              │
│  • Diazepam IV/PR                           │
│  • Midazolam IM (if no IV access)           │
└─────────────┬───────────────────────────────┘
              │  Seizure continues?
              ▼
┌─────────────────────────────────────────────┐
│  PHASE 2 — Second-line ASD (20–40 min)      │
│  • Fosphenytoin / Phenytoin IV              │
│  • Valproic acid IV                         │
│  • Levetiracetam IV                         │
│  • Phenobarbital IV                         │
└─────────────┬───────────────────────────────┘
              │  Seizure continues?
              ▼
┌─────────────────────────────────────────────┐
│  PHASE 3 — Refractory SE (> 40–60 min)     │
│  • Intubate + ICU admission                 │
│  • Anesthetic doses:                        │
│    – Propofol infusion                      │
│    – Midazolam infusion                     │
│    – Pentobarbital infusion                 │
│    – Ketamine infusion                      │
│  • Continuous EEG monitoring MANDATORY      │
│  • Aim: burst suppression pattern on EEG   │
└─────────────────────────────────────────────┘

NCSE: treat urgently using same approach as GCSE
(EEG confirmation required; less metabolic urgency but still causes neuronal injury)

• I have strong training knowledge of Bailey & Love's Short Practice of Surgery, so I can answer questions from memory of its content — classifications, operative steps, management algorithms, etc.
• Just ask your question and mention "from Bailey & Love" — I'll answer based on what I know from that book and flag if I'm uncertain.

• Schwartz's, Sabiston, Mulholland & Greenfield, and Current Surgical Therapy are all available and searchable. For most surgical topics these are equally authoritative — and in many cases more detailed than Bailey & Love.

Medical Examination of the Rape Victim

Objectives of the Examination

1. Search for physical signs (injuries) that corroborate the victim's history
2. Search for, collect and preserve all physical (trace) evidence for laboratory examination
3. Treat the victim for injuries and protect against venereal disease or pregnancy
4. Prevent or lessen permanent psychological damage

Legal Framework (BNS/BNSS)

• Section 52, BNSS (S. 164A, Cr.P.C.): Examination must be conducted by a Registered Medical Practitioner (RMP) in a government/local authority hospital. Examination must not be done without the woman's consent (or competent person's consent on her behalf). Examination must be done without delay; report forwarded to the investigating officer and then to the magistrate.
• Section 200, BNS: Punishment for a doctor who refuses to provide medico-legal examination and treatment of sexual assault victims — imprisonment up to 1 year or fine or both.
• Section 397, BNSS (S. 357C, Cr.P.C.): All hospitals (public/private) must provide first-aid and treatment free of cost and immediately inform police.
• ONE STOP CENTRES have been established at all District Hospitals for medical, legal, and social support.

General Procedure

1. Examination is done only when requisition is received from the investigating police officer or Magistrate — the court/police cannot force a woman to be examined against her will.
2. Written, witnessed consent of the woman must be obtained for examination, specimen collection, photography, and release of information to police. If under 12 years or of unsound mind → parents' written consent required.
3. Victim should be identified by the escorting police constable; identification marks noted.
4. Record: name, age, address, marital status, residence, occupation, time, date, year, place of examination, and by whom requisition was given.
5. Examination in the presence of a third person — preferably a female nurse or female relative.
6. Examination carried out without delay (minor injuries fade within hours; spermatozoa diminish with time).
7. Victim examined in presence of a female attendant to avoid accusations against the examiner.

History Taking

• (a) Preliminary affairs — does she know the accused? Was food/drink given?
• (b) Date, time, place of the alleged offence
• (c) Location: inside/outside, wet/dry weather
• (d) Number of alleged assailants
• (e) Alcohol or drugs involved
• (f) Restraints or weapons used
• (g) Details of struggle/resistance; injuries on body
• (h) Injuries sustained by the assailant (scratches, bites)
• (i) Exact relative positions of the parties
• (j) Type and number of sexual acts
• (k) Use of condoms; disposal of sanitary pads/tampons
• (l) Pain experienced at time or subsequently
• (m) Ejaculation inside vagina or outside
• (n) Appearance of any discharge; bleeding from vagina
• (o) Calls for help
• (p) Recent consensual intercourse (if married woman)
• (q) Consciousness lost at any time
• (r) Post-assault details: changed/washed clothing; bathed/douched/defecated/urinated; hair combed; alcohol/drugs/treatment taken
• (s) Time of first complaint; reason for any undue delay

Examination Proper

(A) Clothes

• Examine clothes worn at time of assault (or ask if changed)
• Patient stands on a clean sheet of paper; everything that falls is preserved (earth, buttons, hair, fibers, gravel, leaves)
• Each item examined for: blood, seminal fluid, mud, earth, grease, grass, tears, loss of buttons, and soiling
• Semen found on underclothing due to vaginal drainage (especially in upright position)
• Clothes dried, stored in clean paper bag, sent to laboratory
• Suspicious stains preserved for chemical analysis
• Vulval pads and vaginal tampons preserved
• Clothes are very important in corroborating or contradicting the victim's story

(B) General Examination

• Examine using ultraviolet light to detect seminal stains
• All soiling areas noted and swabbed with plain cotton swabs
• Loose hair or foreign substances on skin collected
• Large and close-up photographs of injuries taken
• Whole body examined for marks of violence — scratches, bruises, lacerations, tenderness
• Specific injury sites:
  • Petechiae on face/conjunctivae → partial asphyxia (forcible restraint)
  • About mouth/throat — blows to prevent calling for help
  • Bruising of lips/inner aspect
  • About wrists/arms — where man seized her
  • On back, shoulders, buttocks — from pressure on hard ground
  • On thighs (inner and outer aspects)
  • Breasts — bruises, bite marks, love-bites, discoid bruises (1–2 cm) around nipples, neck, face, shoulders, chest wall, lower abdomen, upper thighs
  • Suction lesions (hickeys): circular/oval bruising with intradermal petechial hemorrhages
• Marks of general violence found in one-third of cases
• Absence of general injuries may be due to: submission from fear, insufficient force, bruises not yet visible (may not appear for 48 hours), delay in reporting

(C) Hair

• Pubic hair combed — non-matching male pubic hair and foreign material may be present
• In living victim: 15–20 hairs cut, not pulled
• Head hair samples from front, top, back, left side, right side
• Pubic bone area hairs differ from vaginal/scrotal area hairs → both sampled
• All samples sealed, labelled, sent to laboratory

(D) Seminal Stains

• If pubic hair matted → cut as close to skin as possible
• Pooling of seminal fluid in vagina = sign of recent intercourse, but disappears rapidly in upright posture
• Swabs taken from introitus and perineum first (seminal fluid may leak from vagina), before hymen is examined
• A low vaginal swab taken by gently separating labia minora (without touching labia or perineum)
• Accessible tampons removed → small vaginal speculum introduced → high vaginal swab under direct vision
• Swabs taken before any digital examination
• If gross external injury or very young child → anesthesia may be needed before speculum
• Cervical mucus swab if offence was >48 hours back
• Aspirate from posterior fornix (10 mL normal saline instilled, then aspirated) → examined for living sperms
• Smears prepared immediately and air-dried; then fixed by heat or fixative (absolute alcohol + ether)
• Slides labeled with diamond pencil
• Cervical canal gives best results
• Third swab air-dried → clean dry test tube → acid phosphatase determination
• Seminal soiling areas show fluorescence under UV lamp
• External genitals, buttocks, abdomen, and hands swabbed with saline-moistened cotton swab

(E) Blood Stains

• Presence/absence of blood around vagina and legs noted
• Determine whether due to menstruation
• Profuse bleeding washes out seminal contents → spermatozoa not found

(F) Venereal Disease

• Any discharge (gonorrhea, inflammation, syphilis signs) noted
• Degree of normal cleanliness of the woman noted
• STDs to look for: Chlamydia, trichomoniasis, herpes simplex, HIV, HPV

Genital Examination

Position

• Woman placed on table in good light, legs drawn up and widely open (lithotomy position)
• In gross external injury or very young children → cocaine solution applied to parts first

Questions the Examination Must Answer

1. Is there evidence of recent sexual intercourse?
2. Is there evidence of previous sexual intercourse?
3. Do physical signs confirm use of force or stupefying drugs?
4. Are physical findings consistent with the history?
5. Does medical evidence confirm the allegation?
6. Have all relevant specimens been collected?

Genital Injuries

Genital injuries present in approximately ONE-FIFTH of cases because:

• The alleged sexual act may consist of only rubbing/touching genitalia
• Victim is sexually experienced
• Elasticity of genitalia and hymen in a post-pubertal female
• Use of lubricants

Hymen

• Rupture of hymen with first intercourse = main evidence of rape in a virgin if the hymen was present and covering the anterior vaginal opening
• Tearing occurs posteriorly, between 5 and 7 o'clock, most frequently in the midline of the hymen
• More than two tears are unusual; several hymenal lacerations indicate first sexual intercourse
• After the act: margins sharp and red, bleed on touch, tissues round are tender
• 8–24 hours: margins oedematous, sero-sanguineous oozing
• 2–3 days: pain, congestion, blood-stained fluid oozing
• Day 3: slight oedema, swelling without oozing
• 3–4 days: edges congested and swollen
• 1 week: completely heal (but do not unite)
• Over months: V-shaped tears become rounded, U-shaped defects
• Tears due to digital penetration or tampons do not extend to hymenal margin; tears due to penile penetration extend to the margin; full finger penetration can extend to the hymenal margin
• Fimbriated hymen: moistened swab used to visualize edges
• Toluidine Blue Dye Test: applied to posterior fourchette and fossa navicularis; uptake positive (blue coloring) affirms injury/lacerations

Labia

• Red and inflamed with slight oedema of the vaginal introitus
• Fingernail scratches may be present, especially on labia minora
• Small tears (few mm) in fourchette and fossa navicularis region

Vagina

• Speculum examination; high vaginal swab taken under direct vision
• Inspect for abrasions, bruising, laceration of vaginal walls/vault
• Bruising seen as dark-red area, becomes deep-red/purple within 24 hours
• More frequent on anterior vaginal wall (lower third) and posterior wall (upper third)
• Abrasion of vaginal mucosa more frequent in digital penetration
• Frank laceration of vaginal wall/vault rare in women of child-bearing age but can occur in very young children and atrophic post-menopausal vagina
• Bruising/abrasion/laceration at all times consistent with forcible intercourse with a consenting woman → do not necessarily indicate rape

Cervix

• Abrasion and vaginal occur almost invariably due to vaginal penetration
• Erosions: bright-red areas around external os — may bleed on contact
• Colposcope (5–30× magnification) can be used to directly visualize cervix

Special Situations

Rape on a Virgin

• Examine pubic area; combed area retained for laboratory
• Inspect tops of thighs, labia, perineum; note injuries
• Swabs from introitus and perineum first

Rape on Deflorate Women

• Hymen completely absent or in form of chronicle/tags
• Vaginal orifice dilated; mucous membrane wrinkled and thickened
• Only proof of penetration = presence of spermatozoa in the vagina
• If woman offers resistance → local injury present

Rape on Children

• Few or no signs of general violence (child usually cannot resist and has no idea of what is happening)
• Contusions over inner aspects of thighs (attempt to separate and hold)
• Hymen deeply situated; penetration of adult organ usually impossible due to disproportionate size
• Penis usually placed within vulva or between thighs; hymen usually intact
• Full penile penetration → extensive hematoma affecting anterior and posterior vaginal walls; anterior tears involve bladder; posterior tears involve anorectal canal; vaginal vault may rupture; vaginal herniation of abdominal viscera possible
• Bleeding is brisk; normally stops within 5–10 minutes
• Absence of marks of violence in an early examination = strong evidence that rape has not been committed
• In digital penetration of infant vagina: scratching, laceration or bruising of labia, hymen, fourchette, injury to cervix; circumferential tears are absent

Rape on Old Women

• Senile atrophy and friability → bruising and extensive vaginal lacerations and perineal trauma
• Spontaneous rupture of vagina can occur

Corroborative Signs of Rape

(1) Seminal Fluid

• Spermatozoa in vagina = proof of sexual connection, not of rape
• Absence is not proof that connection has not taken place
• Spermatozoa lose motility within 1–6 hours; motile sperms rarely seen beyond 12 hours after ejaculation
• Sperms recovered up to 24 hours from the vagina

(2) Vaginal Discharges

• Any fluid from vulva picked up with clean pipette and preserved
• In gonorrhea: mucopurulent discharge in 2–4 days
• Smears from cervix and urethra for gonococci (kidney-shaped, intracellular, Gram-negative diplococci)
• Blood sample for syphilis serology

(3) Struggle Signs

• Broken/bent fingernails (can be matched by stria on undersurface); debris under nails (blood, fibers, hair, skin fragments from accused)

Findings Related to Time of Assault

Specimens to Be Collected from Victim (SAFE/PERK Kit)

1. Hair: 10 hairs cut close to roots from different head locations; pubic hair combings; avulsed pubic hair; loose hair from anywhere on body; matted pubic hair
2. Finger scrapings (blood/tissue from accused)
3. Blood: 5 mL plain (grouping) + 5 mL EDTA (DNA profile) + 5 mL sodium fluoride + potassium oxalate (alcohol and drugs and VD)
4. Urine: sodium fluoride (alcohol/secretor grouping)
5. Saliva (secretor grouping)
6. Swabs: from any body surface kissed/licked/sucked/bitten for saliva; genital swabs from introitus, vagina, cervical os; swabs from any soiled skin areas
7. Condoms (if used during intercourse)
8. Sanitary towels/tampons worn after intercourse
9. Vaginal epithelial cells for DNA study

All bottles, tubes, packages must be sealed and labelled with: date and time of examination, time of collection, identification of victim/accused, case number, place of examination.

Evidence of Rape Obtained From

1. Marks of violence on the person of victim and accused
2. Marks of violence about the genitals
3. Presence of seminal stains on clothes/body of victim or accused
4. Presence of seminal matter in the vagina
5. Existence of gonorrhea or syphilis in both parties

Medical Evidence is always corroborative — it may or may not exist.

Opinion / Medico-Legal Report

• Rape is not a medical diagnosis; it is only a legal definition.
• Medical proof of genital penetration is not legal proof of rape.
• The report must contain negative as well as positive findings.
• The doctor should never make a diagnosis of rape.
• Doctor may give opinion that: there are signs of recent vaginal penetration, recent intercourse, general physical injuries, and/or intoxication, and that the signs are consistent with the history given.
• The report must precisely state all reasons for each conclusion.
• The report must specifically record that consent of the woman (or competent person) had been obtained.
• The exact time of commencement and completion of the examination must be noted.
• Report forwarded without delay to the investigating officer → forwarded to the magistrate.

Complications of Rape

1. Death — from shock, hemorrhage from genitals/perineum, suffocation, strangulation
2. Mental derangements, convulsions, epileptic fits — psychological trauma is much greater when the victim knows the rapist
3. Disruption of the victim's physical, social, and sexual life
4. Rape Trauma Syndrome (a form of PTSD — Burgess et al.):
   • Phase 1 — Immediate/acute (disorganization): tension, guilt, humiliation
   • Phase 2 — Long-term (reorganization): nightmares, phobias, readjustment