Seizure

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
  • 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
  • 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)

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
  • Todd paralysis
  • Lateral tongue biting - 100% specificity

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

Differential Diagnosis

Differential diagnosis of seizures

Seizure

Evaluation

Physical

Work-Up

First-Time Seizure or Change in Baseline Seizures

Known Epileptic with NO Change in Baseline Seizures

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)[9]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[10] - may also be given IN
    • Lorazepam IV 2 mg or 0.1 mg/kg
    • Diazepam IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg)
  • Secondary medications
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min
    • 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
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy)
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
  • 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[11]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[12]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[13]
      • 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)[14]
  • Others

Other Considerations

Disposition

First-Time Seizure

  • 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 (comorbidities, age > 60y, cancer, immunocompromise, cardiovascular disease)
    • 24-hr recurrence of seizures in this group is about 9% when alcohol-related events are excluded[15]
  • Instructions not to drive, swim, or participate in other potentially dangerous activities is important
  • Outpatient neurology follow-up

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. Fisher RS. Serum prolactin in seizure diagnosis: Glass half-full or half-empty?. Neurol Clin Pract. 2016;6(2):100-101.
  9. 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.
  10. 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
  11. Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  12. 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.
  13. 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.
  14. Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
  15. 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.