Seizure
Background
Types
- Generalized (consciousness always lost)
- Tonic-clonic
- Absence
- Other (myoclonic, tonic, clonic, atonic)
- Partial (focal)
- Simple partial (no alteration of consciousness)
- Complex partial (consciousness impaired)
- Partial seizures w/ secondary generalization
Precipitants (known seizure disorder)
- Medication noncompliance
- Sleep deprivation
- Infection
- Electrolyte disturbance
- ETOH or substance withdrawal
- Substance abuse
Causes (First-Time Seizure)
- Idiopathic
- Trauma (recent or remote)
- Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
- Structural CNS abnormalities
- Vascular lesion (aneurysm, AVM)
- Mass lesions (primary or metastatic neoplasms)
- Degenerative neurologic diseases
- Congenital brain abnormalities
- Infection (meningitis, encephalitis, abscess)
- Metabolic disturbances
- Hypo- or hyperglycemia
- Hypo- or hypernatremia
- Hyperosmolar states
- Uremia
- Hepatic failure
- Hypocalcemia, hypomagnesemia (rare)
- Toxins and drugs
- Cocaine, lidocaine
- Antidepressants
- Theophylline
- Alcohol withdrawal
- Drug withdrawal
- Eclampsia of pregnancy (may occur up to 8wks postpartum)
- Hypertensive encephalopathy
- Anoxic-ischemic injury (cardiac arrest, severe hypoxemia)
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)
DDX
- Syncope
- Pseudoseizures
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
Diagnosis
- Abrupt onset
- Brief duratoin (typically <2min)
- AMS
- Purposeless activity
- Unprovoked
- Postictal state
Work-Up
Known Seizure Disorder
- Glucose
- Pregnancy test
- Anticonvulsant levels
New Diagnosis
- Glucose
- CBC
- Chemistry
- Pregnancy test
- Utox
- Head CT
- 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 (sz >5min)
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
- Consider secondary causes of seizure (e.g. hyponatremia, INH overdose, ecclampsia)
- Consider EEG to rule-out nonconvulsive status
- Consider prophylactic intubation
- Meds
- First-Line
- [Lorazepam 2mg IV (up to 0.1mg/kg) OR diazepam 5-10mg IV (up to 0.15mg/kg)] AND
- Phenytoin 20-30mg/kg at 50mg/min OR fosphenytoin 20-30mg/kg/PE at 150mg/min
- Phenytoin/fosphenytoin contraindicated in pts w/ 2nd or 3rd degree AV block
- Phenytoin may cause hypotension due to propylene glycol diluent
- Fosphenytoin may be given IM
- Refractory
- Valproic acid 20-40mg/kg at 5mg/kg/min OR
- Phenobarbital 20mg/kg at 50-75mg/min (be prepared to intubate) OR
- Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
- Midazolam 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
- Ketamine 1.5mg/kg then 0.01-0.05mg/kg/hr
- Contraindicated in pts w/ intracranial masses
- First-Line
No IV
- Midazolam IM 0.2mg/kg OR
- Diazepam PR 0.5-1.0mg/kg (up to 20mg)
Disposition
- Typical seizure with known seizure history, normal w/u: discharge after reload
- New onset seizure: Discharge with neuro follow up
- Status epilepticus: Admit ICU
See Also
Source
Tintinalli