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.
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