Seizure

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This page covers seizures in general; refer to Status epilepticus for persistently seizing patients and seizure (peds) for pediatric patients.

Background

  • Caused by a pathologic pattern of brain cortex activity → involuntary movement or change in level of consciousness[1]
    • 11% of people will have at least one seizure in their lifetime
    • 3% will have epilepsy (at least 2 unprovoked seizures)
  • In pregnancy >20 WGA or <4wks postpartum, need to consider eclampsia
    • Most seizures in pregnancy are not first-time seizures, but rather are due to medication noncompliance or pharmacokinetic drug changes as result of pregnancy

Seizure Types

Classification is based on the international classification from 1981[2]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[3]

Focal seizures

(Older term: partial seizures)

  • Without impairment in consciousness– (AKA Simple partial seizures)
    • With motor signs
    • With sensory symptoms
    • With autonomic symptoms or signs
    • With psychic symptoms (including aura)
  • With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
    • Simple partial onset, followed by impairment of consciousness
    • With impairment of consciousness at onset
  • Focal seizures evolving to secondarily generalized seizures
    • Simple partial seizures evolving to generalized seizures
    • Complex partial seizures evolving to generalized seizures
    • Simple partial seizures evolving to complex partial seizures evolving to generalized seizures

Generalized seizures

  • Absence seizures (Older term: petit mal)
    • Typical absence seizures
    • Atypical absence seizures
  • Myoclonic seizure
  • Clonic seizures
  • Tonic seizures
  • Tonic–clonic seizures (Older term: grand mal)
  • Atonic seizures

Clinical Features

  • Abrupt onset, may be unprovoked
  • Brief duration (typically <2min)
  • AMS
  • Jerking of limbs
  • Postictal drowsiness/confusion

Seizure vs. Syncope[4]

  • Factors that strongly favor seizure from most specific to least:
    • Waking with cut tongue
    • Abnormal behavior noted by bystanders
    • LOC with emotional stress
    • Postictal confusion
    • Head turning to one side during LOC
    • Prodromal deja vu or jamais vu
  • Factors that predict against seizure
    • Presyncopal spells
    • Prodromal vertigo
    • LOC with prolonged standing, sitting
    • Diaphoresis, vertigo, nausea, chest pain, feeling of warmth, palpitations, dyspnea before spell

Differential Diagnosis

Differential diagnosis of seizures

Seizure

Evaluation

Physical

  • Check for:
    • Head / C-spine injuries
    • Tongue/mouth lacs
      • Sides of tongue (true seizure) more often bitten than tip of tongue (Psychogenic nonepileptiform seizures, formerly "pseudoseizure.")
      • Tongue biting has sensitivity of ~25% and approaches 100% specificity in lateral tongue biting[5]
    • Posterior shoulder dislocation
    • Focal deficit (Todd paralysis vs CVA)

Work-Up

Known Epileptic with NO Change in Baseline Seizures

  • Anticonvulsant drug concentration
  • Fingerstick glucose
  • Close out-patient follow-up
  • Check for signs of trauma, cervical spine tenderness
  • Consider head CT scan if suspicious of change in pattern, prolonged postictal period or trauma

New Seizure or Change in Baseline Seizures

  • Consider: Pregnancy test, glucose, Electrolytes (Na, Ca, BUN, Crt), RPR, HIV, UA, EEG, lumbar puncture
  • Always perform ECG as prolong QT and torsades can cause shaking after intermitent runs
  • Non-contrast CT in ED or advanced imaging arranged as outpatient
  • Neurology follow up or consult

Management

Management of seizures
  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Benzodiazepine (Initial treatment of choice)[6]
    • Midazolam IM 10mg (>40kg), 5mg (13-40kg), or 0.2mg/kg[7] - may also be given IN
    • Lorazepam IV 2mg or 0.1mg/kg
    • Diazepam IV 0.15-0.2mg/kg (up to 10mg) or PR 0.2-0.5mg/kg (up to 20mg)
  • Secondary medications
    • Fosphenytoin IV 20-30mg/kg at 150mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
    • Valproic acid IV 20-40mg/kg at 5mg/kg/min
    • Levetiracetam IV 60mg/kg, max 4500mg/dose
    • Phenobarbital IV 20mg/kg at 50-75mg/min (be prepared to intubate)
  • Refractory medications
    • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[8]
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[9]
  • Consider

Disposition

First Time Seizures

  • Those with single generalized seizure and otherwise normal history and physical can be discharged home with close follow-up
  • Observation is not unreasonable for those that look ill or have a complicating history/physical
  • 24-hr recurrence of seizures in this group is about 9% when alcohol-related events are excluded[10]
  • Instructions not to drive, swim, or participate in other potentially dangerous activities is important

See Also

External Links

References

  1. Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
  2. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
  3. Epilepsia 2015; 56:1515-1523.
  4. Sheldon R et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.
  5. Benbadis SR et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27;155(21):2346-9.
  6. Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  7. McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  8. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  9. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
  10. Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007; 69(21):1996-2007.