Seizure: Difference between revisions
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*Anoxic-ischemic injury ([[cardiac arrest]], severe hypoxemia) | *Anoxic-ischemic injury ([[cardiac arrest]], severe hypoxemia) | ||
== | ==Clinical Presentation== | ||
* | *Abrupt onset, unprovoked | ||
* | *Brief duratoin (typically <2min) | ||
* | *[[AMS]] | ||
* | *Jerking of limbs | ||
* | *Postictal drowsiness/confusion | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Diagnosis== | ==Diagnosis== | ||
* | ===Physical=== | ||
* | *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) | |||
==Work-Up== | ===Work-Up=== | ||
===Known Seizure Disorder=== | ====Known Seizure Disorder==== | ||
*Glucose | *Glucose | ||
*Pregnancy test | *Pregnancy test | ||
*Anticonvulsant levels | *Anticonvulsant levels | ||
===First-Time Seizure=== | ====First-Time Seizure==== | ||
*Glucose | *Glucose | ||
*CBC | *CBC | ||
| Line 83: | Line 84: | ||
*Pregnancy test | *Pregnancy test | ||
*Utox | *Utox | ||
*Head CT | *[[Head CT]] | ||
*LP (if SAH or meningitis/encephalitis is suspected) | *[[LP]] (if SAH or meningitis/encephalitis is suspected) | ||
===Indications for Head CT<ref>ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625</ref>=== | ===Indications for Head CT<ref>ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625</ref>=== | ||
Revision as of 17:53, 1 May 2015
Background
Types
- Simple (consciousness not impaired)
- Complex (consciousness necessarily impaired)
- Generalized (diffuse brain overactivity)
- Tonic-clonic, tonic, clonic, myoclonic
- Absence
- Atonic
- Partial (specific area in brain affected)
- Partial seizures with secondary generalization
Precipitants (known seizure disorder)
- Medication noncompliance
- Sleep deprivation
- Infection
- Electrolyte disturbance
- Substance withdrawal (eg alcohol, BZPs)
- Substance intoxication
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
- Hypoglycemia or hyperglycemia
- Hyponatremia 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)
Clinical Presentation
- Abrupt onset, unprovoked
- Brief duratoin (typically <2min)
- AMS
- Jerking of limbs
- Postictal drowsiness/confusion
Differential Diagnosis
- Syncope
- Pseudoseizures
- Meningitis
- Encephalitis
- Intracranial Hemorrhage
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
Diagnosis
Physical
- 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)
Work-Up
Known Seizure Disorder
- Glucose
- Pregnancy test
- Anticonvulsant levels
First-Time Seizure
- Glucose
- CBC
- Chemistry
- Pregnancy test
- Utox
- Head CT
- LP (if SAH or meningitis/encephalitis is suspected)
Indications for Head CT[1]
- First seizure if age older than 40
- History of acute head trauma
- History of malignancy
- Immunocompromised status
- Suspect Intracraneal Process
- History of anticoagulation
- New focal neurologic deficit
- Focal onset before generalization
- Persistently altered mental status
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 can be used however Lorazepam IM or IV is generally first line[2]
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
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[4]
First-Time Seizure
- No treatment necessary if pt has[5]:
- 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
- If pregnancy >20wks and <4wks postpartum consider eclampsia
- Most seizures in pregnancy are not first-time seizures
- Due to pharmacokinetic drug changes as result of pregnancy or med noncompliance
Disposition
- Typical seizure with known seizure history, normal w/u
- Discharge after reload
- New onset seizure
- Discharge (no need to start antiepileptic)[6] with neuro follow up
- Status epilepticus
- Admit ICU
See Also
Source
- ↑ ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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