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

New Diagnosis

1. Glucose
2. CBC
3. Chemistry
4. Pregnancy test
5. Utox
6. Head CT
7. LP (if SAH or meningitis/encephalitis is suspected)

Treatment

Actively Seizing

• Protect pt from injury
  • If possible place pt on side to reduce risk of aspiration
  • Do not place bite block
  • Ensure clear airway after seizure stops
• Most seizures stop on their own; meds only indicated for status

History of Seizure

• Identify and correct potential precipitants
• Reload seizure medication if necessary: Seizure Levels and Reloading

First-Time Seizure

• No treatment necessary if pt has:
  • 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

Status Epilepticus

• Continuous or intermittent seizures >5 min without recovery of consciousness

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

1. Ativan 2mg IVP (or Valium 5-10mg IVP)
2. Ativan 2mg IVP
3. 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
4. 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

• Seizure Levels and Reloading
• Seizure (Peds)
• Febrile Seizure

Source

Tintinalli