Seizure

Background

SYNCOPE VS. SEIZURE

1. twitches vs more sig movements
2. quick return baseline vs postictal
3. none vs retrograde amnesia
4. none vs loss of continence
5. tongue biting (tip) vs tongue biting (sides)

Diagnosis

1. Abrupt onset
2. Brief duratoin (typically <1.5min)
3. AMS
4. Purposeless activity
5. Unprovoked
6. Postictal state

DDX

1. Syncope
2. Hyperventilation
3. Breath-holding (children)
4. Toxic/metabolic
   1. ETOH
   2. Hypoglycemia
   3. Tetanus
   4. Strychnine/camphos
   5. Extrapyramidal reaction
5. CNS event
   1. TIA
   2. Narcolepsy
   3. Carotid sinus hypersens
6. Movement disorder
   1. Hemiballismus
   2. Tic
7. Psych
   1. Pseudoseizure
   2. Fugue
   3. Panic attack
8. Seizure
   1. Primary (epilepsy)
      1. Subtheraputic level
   2. Secondary
      1. Encephalitis
      2. Poisoning
      3. Encephalopathy
      4. Metabolic disorder
      5. Pregnancy (eclampsia)
      6. CNS infection
      7. CNS tumor
      8. Supratheraputic levels
      9. Febrile

Workup

Typical with Known Sz Hx

1. Icon
2. Glucose check
3. Anticonvulsant levels
4. +/- CBC & Chem 10
5. +/- Utox

New Onset

1. Icon/Glu check
2. Head CT (*ED or short F/U if return nl)
3. ECG
4. CXR
5. UA/Utox
6. ETOH
7. CBC, Chem 10, LFTs
8. Anticonvulsant levels
9. DMV form/driving instructions

-neuro-

1. LP
2. HIV, ESR, RPR, ANA
3. EEG

Treatment

Status = Sz >10min or intermittent without recovery >10min

1. O2/airway/protection
2. Glu & Icon check (consider D50W)
3. Ativan 2mg IVP (or Valium 5-10mg IVP)
4. Ativan 2mg IVP
5. Dilantin (phenytoin) 1gm over 20min
   1. (20mg/kg no faster than 50mg/min)
   2. contraindicatd in heart block
   3. monitor BP/rythm strip
   4. follow with dilantin 300mg PO QHS
6. If continued, give Phenobarb 1gm over 20min
   1. (20mg/kg no faster than 50mg/min)
   2. prepare to intubate

NO IV

1. versed (midazolam) IM (0.2mg/kg)
2. valium (diazepam) PR (0.5-1.0mg/kg up to 20mg)

Refractory Seizure

1. hyponatremia (infants, psych, etc) --> 3%NS
2. isoniazide overdose --> pyridoxine
3. ecclampsia?

Refractory Status Epilepticus, can also consider one of the following:

1. High Dose Phenytoin (30mg/kg)
2. Valproic Acid
3. Propofol

Disposition

Negative workup:

1. Typical with known seizure history --> home after reload
2. New onset --> home with neuro follow up (admit to Neuro at Harbor for expedited MRI)

See Also

Neuro: Seizure Levels and Reloading

Peds: Seizure (Peds)

Peds: Febrile Seizure

Source

2/27/06 DONALDSON

2/20/10 PANI