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

SUDEP[4]

  • Sudden Unexpected Death in Epilepsy
  • Generalized tonic-clonic seizure is the major risk factor for SUDEP, and seizure freedom is strongly associated with decreased risk
    • Annual incidence of SUDEP in children is 1 in 4500
    • Incidence in adults is 1 in 1000

Clinical Features

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

Seizure vs. Syncope[5]

  • 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

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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[6]
    • Posterior shoulder dislocation
    • Focal deficit (Todd paralysis vs CVA)

Work-Up

Known Epileptic with NO Change in Baseline Seizures

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

New Seizure or Change in Baseline Seizures

  • Non-contrast head CT in ED (or advanced imaging arranged as outpatient)
    • First time seizures in setting of EtOH or EtOH-withdrawal: 6.2% had clinical significant lesion.[7]
  • Point-of-care glucose
  • Pregnancy test
  • CBC & chemistry
  • ECG (prolong QT and torsades can cause shaking after intermitent runs}
  • Consider: Utox, RPR, HIV, UA, EEG, lumbar puncture
  • Neurology follow up or consult

Management

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Management of seizures

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!

Medications

  • Benzodiazepine (Initial treatment of choice)[8]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[9] - may also be given IN
    • Lorazepam IV 2 mg or 0.1 mg/kg
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg)
  • Secondary medications
    • Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose
  • 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[10]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[11]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[12]
      • Then continuous infusion at 0.5-4.0 mg/kg/hr
      • Dose adjusted to suppression-burst pattern on continuous EEG
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[13]

Other Considerations

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[14]
  • 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. Harden C et al. American Academy of Neurology and the American Epilepsy Society. Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors. Neurology April 25, 2017 vol. 88 no. 17 1674-1680.
  5. Sheldon R et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.
  6. Benbadis SR et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27;155(21):2346-9.
  7. Earnest MP, et al. Neurology 1988;38:1561–5.
  8. 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.
  9. 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
  10. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  11. Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  12. Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  13. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
  14. 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.