Seizure: Difference between revisions

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''This page covers seizures in general; refer to [[Status epilepticus]] for persistently seizing patients and [[seizure (peds)]] for pediatric patients.''
==Background==
==Background==
*Simple (consciousness not impaired)
*Caused by a pathologic pattern of brain cortex activity → involuntary movement or change in level of consciousness<ref name="Martindale">Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.</ref>
*Complex (consciousness necessarily impaired)
**11% of people will have at least one seizure in their lifetime
**3% will have epilepsy (at least 2 unprovoked seizures)
*In pregnancy >20 WGA or <4wks postpartum, need to consider [[eclampsia]]
**Most seizures in pregnancy are not first-time seizures, but rather are due to medication noncompliance or pharmacokinetic drug changes as result of pregnancy


{{Seizure types}}
{{Seizure types}}


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


{{Clinical features seizure}}
===Seizure vs. Syncope<ref>Sheldon R et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.</ref>===
*Factors that strongly favor seizure from most specific to least:
**Waking with cut tongue
**Abnormal behavior noted by bystanders
**LOC with emotional stress
**Postictal confusion
**Head turning to one side during LOC
**Prodromal deja vu or jamais vu
*Factors that predict against seizure
**Presyncopal spells
**Prodromal vertigo
**LOC with prolonged standing, sitting
**Diaphoresis, vertigo, nausea, chest pain, feeling of warmth, palpitations, dyspnea before spell


==Differential Diagnosis==
==Differential Diagnosis==
[[File:Seizure Causes.png|thumb|Differential diagnosis of seizures]]
{{Seizure DDX}}
{{Seizure DDX}}


==Diagnosis==
==Evaluation==
===Physical===
===Physical===
*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 (Psychogenic nonepileptiform seizures, formerly "pseudoseizure.")
***Tongue biting has sensitivity of ~25% and approaches 100% specificity in lateral tongue biting<ref>Benbadis SR et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27;155(21):2346-9.</ref>
**Posterior shoulder dislocation
**Posterior shoulder dislocation
**Focal deficit (Todd paralysis vs CVA)
**Focal deficit (Todd paralysis vs CVA)
*** If new, call stroke code ASAP. Cannot be ruled as Todd's without stroke workup.


===Work-Up===
===Work-Up===
====Known Seizure Disorder====
====Known Epileptic with NO Change in Baseline Seizures====
*Glucose
*[[Anticonvulsant levels and reloading|Anticonvulsant drug concentration]]
*Point-of-care glucose
*Close out-patient follow-up
*Check for signs of trauma, cervical spine tenderness
*Consider [[head CT]] scan if prolonged postictal period or trauma
 
====New Seizure or Change in Baseline Seizures====
*Non-contrast [[head CT]] in ED (or advanced imaging arranged as outpatient)
**First time seizures in setting of EtOH or [[EtOH-withdrawal]]: 6.2% had clinical significant lesion.<ref>Earnest MP, et al. Neurology 1988;38:1561–5.</ref>
*Point-of-care glucose
*Pregnancy test
*Pregnancy test
*Anticonvulsant levels
*CBC & chemistry
 
*[[ECG]] ([[prolong QT]] and [[torsades]] can cause shaking after intermitent runs}
{{Head CT seizure}}
*Consider: [[Utox]], RPR, [[HIV]], [[UA]], EEG, [[lumbar puncture]]
 
*Neurology follow up or consult
==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|benzodiazepine]] can be used however [[Lorazepam]] IM or IV is generally first line<ref>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</ref>
 
===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
 
===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
*[[Diazepam]] PR 0.5-1.0mg/kg (up to 20mg)
===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<ref name="a">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</ref>
 
===First-Time Seizure===
*No treatment necessary if pt has<ref name="a" /><ref>Krumholz A, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology 2015; 84(16):1705-1713.</ref>:
**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===
==Management==
*If pregnancy >20wks and <4wks postpartum consider [[eclampsia]]
[[File:Seizure Management.png|thumb|Management of seizures]]
*Most seizures in pregnancy are not first-time seizures
{{Seizure actively seizing management}}
**Due to pharmacokinetic drug changes as result of pregnancy or med noncompliance


==Disposition==
==Disposition==
*Typical seizure with known seizure history, normal w/u
===First Time Seizures===
**Discharge after reload
*Those with single generalized seizure and otherwise normal history and physical can be discharged home with close follow-up
*New onset seizure
*Observation is not unreasonable for those that look ill or have a complicating history/physical
**Discharge (no need to start antiepileptic<ref name="a" />) with neuro follow up
*24-hr recurrence of seizures in this group is about 9% when alcohol-related events are excluded<ref>Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007; 69(21):1996-2007.</ref>
**Risk for recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%)
*Instructions not to drive, swim, or participate in other potentially dangerous activities is important
*Status epilepticus
**Admit ICU


==See Also==
==See Also==
*[[Seizure Levels and Reloading]]
*[[Seizure (Peds)]]
*[[Febrile Seizure]]
*[[Anticonvulsants]]
*[[Anticonvulsants]]
*[[Anticonvulsant levels and reloading]]
*[[Seizure (peds)]]
*[[Febrile seizure]]
*[[Status epilepticus]]
*[[Status epilepticus]]
==External Links==
*[http://ddxof.com/seizure-2/ DDxOf: Differential Diagnosis of Seizures]


==References==
==References==
<references/>
<references/>
[[Category:Neuro]]
 
[[Category:Neurology]]

Revision as of 18:01, 9 April 2019

This page covers seizures in general; refer to Status epilepticus for persistently seizing patients and seizure (peds) for pediatric patients.

Background

  • Caused by a pathologic pattern of brain cortex activity → involuntary movement or change in level of consciousness[1]
    • 11% of people will have at least one seizure in their lifetime
    • 3% will have epilepsy (at least 2 unprovoked seizures)
  • In pregnancy >20 WGA or <4wks postpartum, need to consider eclampsia
    • Most seizures in pregnancy are not first-time seizures, but rather are due to medication noncompliance or pharmacokinetic drug changes as result of pregnancy

Seizure Types

Classification is based on the international classification from 1981[2]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[3]

Focal seizures

(Older term: partial seizures)

  • Without impairment in consciousness– (AKA Simple partial seizures)
    • With motor signs (ex. facial twiching or rhythmic ipsilateral extremity movements)
    • With sensory symptoms (ex. tingling or pereiving a certain smell)
    • With autonomic symptoms or signs (ex. tachycardia or diaphoresis)
    • With psychic symptoms (including aura, ex. sense of déjà-vu)
  • With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
    • Simple partial onset, followed by impairment of consciousness
    • With impairment of consciousness at onset
    • These seizures may be accompanied by automatism (such as lip smacking and chewing, hand wringing, patting and rubbing)
  • Focal seizures evolving to secondarily generalized seizures
    • Simple partial seizures evolving to generalized seizures
    • Complex partial seizures evolving to generalized seizures
    • Simple partial seizures evolving to complex partial seizures evolving to generalized seizures

Generalized seizures

  • Absence seizures (Older term: petit mal; brief dissociative states without postural changes)
    • Typical absence seizures
    • Atypical absence seizures (last longer and often include more motor involvement)
  • Myoclonic seizure (violent muscle contractions)
  • Clonic seizures (rhythmic jerking)
  • Tonic seizures (stiffening)
  • Tonic–clonic seizures (Older term: grand mal)
  • Atonic seizures (loss of muscle tone -> drop attacks)

SUDEP[4]

  • Sudden Unexpected Death in Epilepsy
  • Generalized tonic-clonic seizure is the major risk factor for SUDEP, and seizure freedom is strongly associated with decreased risk
    • Annual incidence of SUDEP in children is 1 in 4500
    • Incidence in adults is 1 in 1000

Clinical Features

  • Abrupt onset, may be unprovoked
  • Brief duration (typically <2min)
  • AMS
  • Jerking of limbs
  • Postictal drowsiness/confusion (typically lasting <30 minutes)
  • Todd paralysis
  • Lateral tongue biting - 100% specificity
  • Incontinence

Seizure vs. Syncope[5]

  • Factors that strongly favor seizure from most specific to least:
    • Waking with cut tongue
    • Abnormal behavior noted by bystanders
    • LOC with emotional stress
    • Postictal confusion
    • Head turning to one side during LOC
    • Prodromal deja vu or jamais vu
  • Factors that predict against seizure
    • Presyncopal spells
    • Prodromal vertigo
    • LOC with prolonged standing, sitting
    • Diaphoresis, vertigo, nausea, chest pain, feeling of warmth, palpitations, dyspnea before spell

Differential Diagnosis

Differential diagnosis of seizures

Seizure

Evaluation

Physical

  • Check for:
    • Head / C-spine injuries
    • Tongue/mouth lacs
      • Sides of tongue (true seizure) more often bitten than tip of tongue (Psychogenic nonepileptiform seizures, formerly "pseudoseizure.")
      • Tongue biting has sensitivity of ~25% and approaches 100% specificity in lateral tongue biting[6]
    • Posterior shoulder dislocation
    • Focal deficit (Todd paralysis vs CVA)
      • If new, call stroke code ASAP. Cannot be ruled as Todd's without stroke workup.

Work-Up

Known Epileptic with NO Change in Baseline Seizures

New Seizure or Change in Baseline Seizures

  • Non-contrast head CT in ED (or advanced imaging arranged as outpatient)
    • First time seizures in setting of EtOH or EtOH-withdrawal: 6.2% had clinical significant lesion.[7]
  • Point-of-care glucose
  • Pregnancy test
  • CBC & chemistry
  • ECG (prolong QT and torsades can cause shaking after intermitent runs}
  • Consider: Utox, RPR, HIV, UA, EEG, lumbar puncture
  • Neurology follow up or consult

Management

Management of seizures

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Jaw thrust, a NPA and oxygen may be required
  • An IV line should be placed

Medications

  • Benzodiazepine (Initial treatment of choice)[8]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[9]
      • May also be given IN at 0.2 mg/kg, max 10 mg
      • OR buccal at 0.3 mg/kg, max 10 mg
    • Lorazepam IV 4 mg or 0.1 mg/kg; may repeat one dose[10]
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg); may repeat one dose or PR 0.2-0.5 mg/kg (up to 20 mg) once [11]
  • Secondary medications
    • ESETT trial[12] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [13] which is Levetiracetam
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[14]
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[15]
    • Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
      • Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg (avoid in pregnancy)[16]
  • Refractory medications
    • Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
    • Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
    • Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[17]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[18]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[19]
      • Then continuous infusion at 0.5-4.0 mg/kg/hr
      • Dose adjusted to suppression-burst pattern on continuous EEG
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[20]
  • Others

Other Considerations

Disposition

First Time Seizures

  • Those with single generalized seizure and otherwise normal history and physical can be discharged home with close follow-up
  • Observation is not unreasonable for those that look ill or have a complicating history/physical
  • 24-hr recurrence of seizures in this group is about 9% when alcohol-related events are excluded[21]
  • Instructions not to drive, swim, or participate in other potentially dangerous activities is important

See Also

External Links

References

  1. Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.
  2. Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
  3. Epilepsia 2015; 56:1515-1523.
  4. Harden C et al. American Academy of Neurology and the American Epilepsy Society. Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors. Neurology April 25, 2017 vol. 88 no. 17 1674-1680.
  5. Sheldon R et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.
  6. Benbadis SR et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27;155(21):2346-9.
  7. Earnest MP, et al. Neurology 1988;38:1561–5.
  8. Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  9. 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
  10. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  11. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  12. Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
  13. PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  14. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  15. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  16. Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  17. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  18. Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  19. Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  20. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
  21. Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007; 69(21):1996-2007.