Seizure: Difference between revisions
 
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''This page covers <u>seizures in general</u>; 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 (time-limited paroxysmal events from abnormal rhythmic neuronal discharges) → 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
*The most common etiology of seizure is noncompliance with medication


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


===Definitions===
{{Clinical features seizure}}
*Seizures: abnormal neuronal activity with various neurological sequale
**Further defined by whether they involve 1 hemisphere (partial) or both hemispheres (generalized). While generalized seizures surely cause an alteration in mental status, seizures involving one hemisphere (partial) may further be subdivided by whether they maintain baseline mental status (simple) or an alteration (complex).
*Epilepsy is defined a 2 or more epileptic seizures that occur unprovoked by any identifiable cause.  This include all seizure events with the exception of febrile or neonatal seizures.
**Further subclassified into cryptogenic (meaning unknown cause) or symptomatic (meaning associated with previous CNS insult).
***Symptomatic seizures further subdefined as acute or remote (depending on if > or < 1 week after CNS insult)
 
*Seizure  type and associated EEG findings are at core of determining risk of recurrence and indication for antiepileptic therapy. Follow the “seizure” link (pending Jan 2014) for more information on the non-acute general treatment of seizures.


{{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
**[[syncope|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 injury|Head]] / [[cervical spine injuries|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 nonepileptic seizure]], formerly "pseudoseizure.")
**Posterior shoulder dislocation
***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>
**Focal deficit (Todd paralysis vs CVA)
**[[Posterior shoulder dislocation]]
**[[focal neuro deficit|Focal deficit]] (Todd paralysis vs [[CVA]])
*** If new, treat as presumed stroke. Cannot be ruled as Todd's without stroke workup.
**Nuchal rigidity (concern for [[meningitis]])


===Work-Up===
===Work-Up===
====[[First-time seizure|First-Time 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 [[Alcohol withdrawal seizures|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
*CBC & chemistry
*[[ECG]] ([[prolonged QT]] and [[torsades]] can cause shaking after intermittent runs}
*Consider prolactin<ref>Fisher RS. Serum prolactin in seizure diagnosis: Glass half-full or half-empty?. Neurol Clin Pract. 2016;6(2):100-101.</ref> or [[lactate]] to assist in differentiating seizures from [[psychogenic nonepileptic seizure]] or volitional seizure activity (lactate may be detectable for up to 1 hour post-seizure)
*Consider: [[Utox]], RPR, [[HIV]], [[UA]], EEG, [[lumbar puncture]], EtOH level, CK


==Treatment==
====Known Epileptic with NO Change in Baseline Seizures====
*[[Anticonvulsant levels and reloading|Anticonvulsant drug concentration]]
*Point-of-care [[hypoglycemia|glucose]]
*Trauma workup, if appropriate
*Consider [[head CT]] scan if prolonged postictal period or trauma
 
==Management==
[[File:Seizure Management.png|thumb|Management of seizures]]
{{Seizure actively seizing management}}
{{Seizure actively seizing management}}


==Special Populations==
==Disposition==
===Pregnancy===
===[[First-time seizure|First-Time Seizure]]===
*If pregnancy >20wks and <4wks postpartum consider [[eclampsia]]
*Those with single generalized seizure and otherwise normal history and physical can be discharged home with close follow-up<ref>Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2014;63(4):437-47.e15. doi:10.1016/j.annemergmed.2014.01.018</ref>
*Most seizures in pregnancy are not first-time seizures
**Observation is not unreasonable for those that look ill or have a complicating history/physical (comorbidities, age > 60y, cancer, immunocompromise, cardiovascular disease)
**Due to pharmacokinetic drug changes as result of pregnancy or med noncompliance
**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>
*Instructions not to drive, swim, or participate in other potentially dangerous activities is important
*Outpatient neurology follow-up


==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]]
*[[Alcohol withdrawal seizures]]
==External Links==
*[http://ddxof.com/seizure-2/ DDxOf: Differential Diagnosis of Seizures]
*[https://www.acep.org/patient-care/clinical-policies/seizure/ ACEP Clinical Policy on Seizure]


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

Latest revision as of 22:18, 12 May 2022

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 (time-limited paroxysmal events from abnormal rhythmic neuronal discharges) → 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
  • The most common etiology of seizure is noncompliance with medication

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

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 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[11]
    • 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 [12]
  • Secondary medications
    • ESETT trial[13] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [14] which is Levetiracetam
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[15]
    • Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[16]
    • 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)[17]
  • Refractory medications
    • Propofol 2-5mg/kg load, then infusion of 30-200mcg/kg/min (equivalent 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[18]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[19]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[20]
      • 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)[21]
  • 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[22]
    • 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[23]
  • 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. ↑ 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. ↑ 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
  13. ↑ 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
  14. ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  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. ↑ 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
  18. ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  19. ↑ 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.
  20. ↑ 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.
  21. ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
  22. ↑ Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2014;63(4):437-47.e15. doi:10.1016/j.annemergmed.2014.01.018
  23. ↑ 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.
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