Seizures – ED

Seizures

1. Consider the possibility of a seizure in the differential diagnosis for a patient with an atypical presentation but without witnessed frank seizure movements (e.g., confused or altered level of consciousness, incontinence, fall/injury/accident, tics in children).

Classifications

  1. Generalized
    1. tonic-clonic / Grand Mal
    2. Absence / Petit Mal: <1min staring spells
    3. Myoclonic
    4. Atonic
  2. Simple partial – consciousness maintained & no post-ictal
    1. Motor: focal tonic movement; Jacksonian march (simple partial progressing to generalized seizure)
    2. Sensory: visual, auditory, oral, olfactory, gustatory
  3. Complex partial (temporal lobe) – no LOC ,but AMS/impairment +/- amnesia
    1. automatisms: lip smacking, repeated swallowing, picking at clothes
    2. hallucinations: olfactory/gustatory – temporal lobe; visual – occipital
    3. may have postictal confusion
  4. Pseudoseizures / PNES (psychogenic non-epilepticus Seizures)
    1. no postictal, acidosis, leukocytosis
    2. normal prolactine level and plantar reflex

2. Given a patient with a seizure, investigate for rapidly reversible causes (e.g., hypoglycemia, toxicology, arrhythmias) and treat promptly.

Secondary causes

  1. Metabolic:
    1. Hypoglycemia (DM), Hyponatremia (neonates/infants), hypocalcemia
  2. Drugs & toxins
    1. anticholinergics/ cholinergics/ sympathomimetics
    2. Antidepressants / toxic alcohols / Mushrooms (gyromitra sp)
    3. Alcohol W/D: BZD/thiamine Tx of choice; may need intubation + phenobarb vs propofol
    4. Drugs: theophylline (asthma), INH (Injures Neurons & Hepatocytes – TB), baclofen w/D; TCA OD (bicarb)
  3. CNS infection – encephalitis / meningitis
  4. CNS lesions / trauma: neurocysticercosis, hemorrhage, tumors, stroke, vasculitis, hydrocephalus
  5. Febrile – simple (<15min, <2/24hr, 6mo-6yo) vs complex; antiepileptics not indicated
    1. prevalent family; Sz w/u not req if simple febrile Sz
    2. LP if: Meningeal signs, <12mo w/o HiB or S. Pneumo Imm, Febrile status epilepticus
    3. risk factor for recurrence: <12mo, lower temp and shorter duration of fever at onset, + family hx, complex febrile Sz
  6. Eclampsia
  7. Pseudo – hysterical epilepsy
  8. Syncope / arrhythmia – ECG for all Sz patients

3. Given a patient with ongoing repeated seizures or persistent altered mental status between seizures, make the diagnosis of status epilepticus and treat promptly.

Status epilepticus

  • Sz >5min or >=2 Sz w/o fully recovery of consciousness between seizures
  • Pt may have EEG discharge even after tonic-clonic movements ended; Must monitor EEG after intubation + paralyzed

4. In a patient who continues to seize actively, manage by:

• Assessing the airway and ventilation and supporting as necessary

• Identifying specific conditions that require treatment other than standard anticonvulsant therapy (e.g., pre-eclampsia, toxidromes)

Reversible causes

  1. infectious – consider empiric abx and acyclovir
  2. Eclampia – up to 6wk postpartum – consider empiric MgSO4 4-6g IV
  3. Isoniazid toxicity – antidote: pyridoxine 5g IV
    1. consider tox causes if unresponsive to drug therapy
  4. Hyponatremia – 100ml (2ml/kg) 3% hypertonic saline; repeat 10min prn
    1. HypoCa/Mg – replace
  5. EtOH W/D – needs more BZD / thiamine
  6. Cyanide – antidote: hydroxycobalamine and cyanide antidote kite – sodium thiosulfate
  7. Structural brain dz if focal Sz – obtain CT
    1. tumor – steroids

• Using anticonvulsants in a progressive fashion to terminate the seizures as promptly as possible

Management of status epilepticus:

  1. airway – roll pt on side to dec aspiration, establish patent airway, suction prn & oxygen through non-rebreather facemask
  2. BZD: Ativan 0.1mg/kg IV & search for reversible causes
    1. consider eclampsia up to 6wk pp – treat empirically w/ MgSO4 4-6g IV
    2. Midazolam IV/IM/IN; Diazepam IV/PR; Ativan IV/IM
    3. Thiamine and glucose if hypoglycemic / EtOH
  3. Check BG, lytes, tox, HCG, liver and renal function
  4. Phenytoin / fosphenytoin (IM/IV) 20mg/kg IV over 10min & prepare for intubation
    1. Give second dose of BZD at the same time – Ativan 0.1mg/kg IV
    2. Phenytoin – nystagmus if therapeutic
  5. Valproic acid 20mg/kg IV or Keppra 40mg/kg IV good safety profile
    1. useful in HoTN, noncompliance to oral valproic acid, sensitive to phenytoin
  6. Intubation – RSI; avoid Etomidate – lowers Sz threshold
    1. induction w/ propofol 1.5mg/kg IV (anti-epileptic), but if HoTN, use Ketamine 2mg/kg
    2. Paralytics – use succinylchoine – watch out for hyperkalemia; rocuroniym increase the risk of nonconvulsive status epilepticus
    3. Consult neuro for EEG to r/o nonconvulsive status epilepticus
    4. Phenobarbital 20mg/kg – respiratory depression, HoTN, long half life
      1. some guideline recommends skip phenobarbital and right to propofol
  7. Obtain CT head and consider LP

5. In a patient who has had a first seizure, counsel regarding high-risk activities and initiate the appropriate procedures for reporting to authorities (e.g., driving/sports/occupation).

No driving, swimming, Bath, other high risk activities

6. Given a patient with a first seizure, investigate to establish the underlying etiology in a timely fashion (e.g., CT, lumbar puncture, EEG, metabolic, toxicologic).

DDx: syncope, dysrhythmia, psychiatric illness, migraines, CVA, SAH

First Time Seizure

  • check Na, Glucose, Ca, Mg, bHCG, urine toxicology
  • CT if any suspicion for serious structural lesion
  • LP if any suspicion for meningitis, SAH, hx of cancer ? mets to brain
  • HIV pt – CT with contrast / MRI
  • EEG during event confirms diagnosis if diagnosis is in question; Out paitent follow up for MRI/EEG if no cause found in ED.
  • Defer initiation of antiepileptics to outpatient neurology unless CNS lesion present

7. In a known epileptic who has had a seizure, investigate appropriately but do not over-investigate without specific indication (e.g., verify compliance and check anticonvulsant levels, consider contributing causes).

Precipitating factors

  • missed medications
  • substance abuse or withdrawal
  • sleep deprivation
  • infection
  • electrolyte disturbances

Recurrent Seizures

  • check glucose and anticonvulsant levels – supratherapeutic level of phenytoin and carbamazepine can result in Sz
  • More extensive evaluation if change in Sz pattern, prolonged postictal or fever
  • Consider medication adjustment

8. In a child with a typical febrile seizure, including a complete recovery, make a diagnosis based on history and physical exam alone, and do not over-investigate.

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