Seizure

Background

Types

  1. Generalized (consciousness always lost)
    1. Tonic-clonic
    2. Absence
    3. Other (myoclonic, tonic, clonic, atonic)
  2. Partial (focal)
    1. Simple partial (no alteration of consciousness)
    2. Complex partial (consciousness impaired)
    3. Partial seizures w/ secondary generalization

Precipitants (known seizure disorder)

  1. Medication noncompliance
  2. Sleep deprivation
  3. Infection
  4. Electrolyte disturbance
  5. ETOH or substance withdrawal
  6. Substance abuse

Causes (First-Time Seizure)

  1. Idiopathic
  2. Trauma (recent or remote)
  3. Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
  4. Structural CNS abnormalities
    1. Vascular lesion (aneurysm, AVM)
    2. Mass lesions (primary or metastatic neoplasms)
    3. Degenerative neurologic diseases
    4. Congenital brain abnormalities
  5. Infection (meningitis, encephalitis, abscess)
  6. Metabolic disturbances
    1. Hypo- or hyperglycemia
    2. Hypo- or hypernatremia
    3. Hyperosmolar states
    4. Uremia
    5. Hepatic failure
    6. Hypocalcemia, hypomagnesemia (rare)
  7. Toxins and drugs
    1. Cocaine, lidocaine
    2. Antidepressants
    3. Theophylline
    4. Alcohol withdrawal
    5. Drug withdrawal
  8. Eclampsia of pregnancy (may occur up to 8wks postpartum)
  9. Hypertensive encephalopathy
  10. Anoxic-ischemic injury (cardiac arrest, severe hypoxemia)

Diagnosis

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

DDX

  1. Syncope
  2. Pseudoseizures
  3. Hyperventilation syndrome
  4. Migraine headache
  5. Movement disorders
  6. Narcolepsy/cataplexy

Diagnosis

  • Abrupt onset
  • Brief duratoin (typically <2min)
  • AMS
  • Purposeless activity
  • Unprovoked
  • Postictal state

Work-Up

Known Seizure Disorder

  1. Glucose
  2. Pregnancy test
  3. Anticonvulsant levels

First-Time Seizure

  1. Glucose
  2. CBC
  3. Chemistry
  4. Pregnancy test
  5. Utox
  6. Head CT
  7. 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

===Indications for Head CT=== [2]

  • 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

Indications for Head CT[3]

  • 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

Disposition

  1. Typical seizure with known seizure history, normal w/u: discharge after reload
  2. New onset seizure: Discharge with neuro follow up
  3. Status epilepticus: Admit ICU

See Also

Source

Tintinalli - Seizures

  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. ↑ 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
  3. ↑ 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
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