Seizure: Difference between revisions
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==Background==
==Background==
===Types===
===Types===
#Simple (consciousness not impaired)
*Simple (consciousness not impaired)
#Complex (consciousness necessarily impaired)
*Complex (consciousness necessarily impaired)
#Generalized (diffuse brain overactivity)
*Generalized (diffuse brain overactivity)
##Tonic-clonic, tonic, clonic, myoclonic
**Tonic-clonic, tonic, clonic, myoclonic
##Absence
**Absence
##Atonic
**Atonic
#Partial (specific area in brain affected)
*Partial (specific area in brain affected)
##Partial seizures with secondary generalization
**Partial seizures with secondary generalization


===Precipitants (known seizure disorder)===
===Precipitants (known seizure disorder)===
#Medication noncompliance
*Medication noncompliance
#Sleep deprivation
*Sleep deprivation
#Infection
*Infection
#Electrolyte disturbance
*Electrolyte disturbance
#Substance withdrawal (eg alcohol, BZPs)
*Substance withdrawal (eg alcohol, BZPs)
#Substance intoxication
*Substance intoxication


===Causes (First-Time Seizure)===  
===Causes (First-Time Seizure)===  
#Idiopathic
*Idiopathic
#Trauma (recent or remote)
*Trauma (recent or remote)
#Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
*Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
#Structural CNS abnormalities
*Structural CNS abnormalities
##Vascular lesion (aneurysm, AVM)
**Vascular lesion (aneurysm, AVM)
##Mass lesions (primary or metastatic neoplasms)
**Mass lesions (primary or metastatic neoplasms)
##Degenerative neurologic diseases
**Degenerative neurologic diseases
##Congenital brain abnormalities
**Congenital brain abnormalities
#Infection (meningitis, encephalitis, abscess)
*Infection (meningitis, encephalitis, abscess)
#Metabolic disturbances
*Metabolic disturbances
##[[Hypoglycemia]] or [[hyperglycemia]]
**[[Hypoglycemia]] or [[hyperglycemia]]
##[[Hyponatremia]] or [[hypernatremia]]
**[[Hyponatremia]] or [[hypernatremia]]
##Hyperosmolar states
**Hyperosmolar states
##[[Uremia]]
**[[Uremia]]
##[[Hepatic failure]]
**[[Hepatic failure]]
##[[Hypocalcemia]], [[hypomagnesemia]] (rare)
**[[Hypocalcemia]], [[hypomagnesemia]] (rare)
#Toxins and drugs
*Toxins and drugs
##[[Cocaine]], [[lidocaine]]
**[[Cocaine]], [[lidocaine]]
##Antidepressants
**Antidepressants
##Theophylline
**Theophylline
##[[Alcohol withdrawal]]
**[[Alcohol withdrawal]]
##Drug withdrawal
**Drug withdrawal
#[[Eclampsia]] of pregnancy (may occur up to 8wks postpartum)
*[[Eclampsia]] of pregnancy (may occur up to 8wks postpartum)
#[[Hypertensive encephalopathy]]
*[[Hypertensive encephalopathy]]
#Anoxic-ischemic injury ([[cardiac arrest]], severe hypoxemia)
*Anoxic-ischemic injury ([[cardiac arrest]], severe hypoxemia)


==Diagnosis==
==Diagnosis==
#Check for:
*Check for:
##Head / C-spine injuries
**Head / C-spine injuries
##Tongue/mouth lacs
**Tongue/mouth lacs
###Sides of tongue (true seizure) more often bitten than tip of tongue (pseudoseizure)
***Sides of tongue (true seizure) more often bitten than tip of tongue (pseudoseizure)
##Posterior shoulder dislocation
**Posterior shoulder dislocation
##Focal deficit (Todd paralysis vs CVA)
**Focal deficit (Todd paralysis vs CVA)


==Differential Diagnosis==
==Differential Diagnosis==
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==Work-Up==
==Work-Up==
===Known Seizure Disorder===
===Known Seizure Disorder===
#Glucose
*Glucose
#Pregnancy test
*Pregnancy test
#Anticonvulsant levels
*Anticonvulsant levels


===First-Time Seizure===
===First-Time Seizure===
#Glucose
*Glucose
#CBC
*CBC
#Chemistry
*Chemistry
#Pregnancy test
*Pregnancy test
#Utox
*Utox
#Head CT
*Head CT
#LP (if SAH or meningitis/encephalitis is suspected)
*LP (if SAH or meningitis/encephalitis is suspected)


===Indications for Head CT<ref>ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625</ref>===
===Indications for Head CT<ref>ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625</ref>===
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===No IV===
===No IV===
#[[Midazolam]] IM 0.2mg/kg<ref>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</ref> OR
*[[Midazolam]] IM 0.2mg/kg<ref>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</ref> OR
#[[Diazepam]] PR 0.5-1.0mg/kg (up to 20mg)
*[[Diazepam]] PR 0.5-1.0mg/kg (up to 20mg)
===History of Seizure===
===History of Seizure===
*Identify and correct potential precipitants
*Identify and correct potential precipitants
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<references/>
<references/>
[[Category:Neuro]]
[[Category:Neuro]]
[[Category:Featured]]

Revision as of 15:18, 1 May 2015

Background

Types

  • Simple (consciousness not impaired)
  • Complex (consciousness necessarily impaired)
  • Generalized (diffuse brain overactivity)
    • Tonic-clonic, tonic, clonic, myoclonic
    • Absence
    • Atonic
  • Partial (specific area in brain affected)
    • Partial seizures with secondary generalization

Precipitants (known seizure disorder)

  • Medication noncompliance
  • Sleep deprivation
  • Infection
  • Electrolyte disturbance
  • Substance withdrawal (eg alcohol, BZPs)
  • Substance intoxication

Causes (First-Time Seizure)

Diagnosis

  • Check for:
    • Head / C-spine injuries
    • Tongue/mouth lacs
      • Sides of tongue (true seizure) more often bitten than tip of tongue (pseudoseizure)
    • Posterior shoulder dislocation
    • Focal deficit (Todd paralysis vs CVA)

Differential Diagnosis

Diagnosis

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

Work-Up

Known Seizure Disorder

  • Glucose
  • Pregnancy test
  • Anticonvulsant levels

First-Time Seizure

  • Glucose
  • CBC
  • Chemistry
  • Pregnancy test
  • Utox
  • Head CT
  • LP (if SAH or meningitis/encephalitis is suspected)

Indications for Head CT[1]

  • First seizure if age older than 40
  • History of acute head trauma
  • History of malignancy
  • Immunocompromised status
  • Suspect Intracraneal Process
  • History of anticoagulation
  • New focal neurologic deficit
  • Focal onset before generalization
  • Persistently altered mental status

Treatment

Actively Seizing

  • Protect pt from injury
    • If possible place pt in left lateral position to reduce risk of aspiration
    • Do not place bite block
    • Ensure clear airway after seizure stops
  • Most seizures self resolve. If a patient is actively seizing then any benzodiazepine can be used however Lorazepam IM or IV is generally first line[2]

Status Epilepticus

  • Continuous or intermittent seizures >5 min without recovery of consciousness
  • Consider secondary causes of seizure (e.g. hyponatremia, INH overdose, ecclampsia)
  • Consider EEG to rule-out nonconvulsive status
  • Consider prophylactic intubation
  • Meds

No IV

History of Seizure

  • Identify and correct potential precipitants
  • Reload seizure medication if necessary: Seizure Levels and Reloading
    • May use IV vs PO reload at physican discretion[4]

First-Time Seizure

  • No treatment necessary if pt has[5]:
    • Normal neuro exam
    • No acute or chronic medical comorbidities
    • Normal diagnostic testing (including normal imaging)
    • Normal mental status
  • Treatment generally indicated if seizure due to an identifiable neurologic condition

Special Populations

Neurocysticercosis

  • Seizures are typically controlled by antiepileptic monotherapy

Pregnancy

  • If pregnancy >20wks and <4wks postpartum consider eclampsia
  • Most seizures in pregnancy are not first-time seizures
    • Due to pharmacokinetic drug changes as result of pregnancy or med noncompliance

Disposition

  • Typical seizure with known seizure history, normal w/u
    • Discharge after reload
  • New onset seizure
    • Discharge (no need to start antiepileptic)[6] with neuro follow up
  • Status epilepticus
    • Admit ICU

See Also

Source

  1. ↑ ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625
  2. ↑ Treiman D, Meyers P, Walton N, et al. A comparison of four treatments for generalized convulsive status epilepticus. New Engl J Med 1998; 339; 792-798
  3. ↑ 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
  4. ↑ Clinical Policy:Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED with Seizures. Annals of EM. April 2014. 63(4);p437-446
  5. ↑ Clinical Policy:Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED with Seizures. Annals of EM. April 2014. 63(4);p437-446
  6. ↑ Clinical Policy:Critical Issues in the Evaluation and Management of Adult Patients Presenting to the ED with Seizures. Annals of EM. April 2014. 63(4);p437-446
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