First-time seizure: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Causes of first-time seizure=== | ===Causes of first-time seizure=== | ||
*Idiopathic | *Idiopathic | ||
*Trauma (recent or remote) | *[[head trauma|Trauma]] (recent or remote) | ||
*Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal) | *[[ICH|Intracranial hemorrhage]] ([[SDH|subdural]], [[epidural hematoma|epidural]], [[SAH|subarachnoid]], intraparenchymal) | ||
*Structural CNS abnormalities | *Structural CNS abnormalities | ||
**Vascular lesion (aneurysm, AVM) | **Vascular lesion (aneurysm, [[AVM]]) | ||
**Mass lesions (primary or metastatic neoplasms) | **[[Brain tumor|Mass lesions]] (primary or metastatic neoplasms) | ||
**Degenerative neurologic diseases | **Degenerative neurologic diseases | ||
**Congenital brain abnormalities | **Congenital brain abnormalities | ||
*Infection (meningitis, encephalitis, abscess) | *Infection ([[meningitis]], [[encephalitis]], [[brain abscess|abscess]]) | ||
*Metabolic disturbances | *Metabolic disturbances | ||
**[[Hypoglycemia]] or [[hyperglycemia]] | **[[Hypoglycemia]] or [[hyperglycemia]] | ||
Line 25: | Line 25: | ||
**[[Cocaine]], [[lidocaine]] | **[[Cocaine]], [[lidocaine]] | ||
**Antidepressants | **Antidepressants | ||
**Theophylline | **[[theophylline toxicity|Theophylline]] | ||
**[[Alcohol withdrawal]] | **[[Alcohol withdrawal]] | ||
**Drug withdrawal | **Drug withdrawal | ||
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{{Seizure DDX}} | {{Seizure DDX}} | ||
== | ==Evaluation== | ||
===Work-up=== | ===Work-up=== | ||
*POC glucose | |||
*CBC | |||
*Chemistry | |||
*Pregnancy test (female) | |||
*[[Urine toxicology screen]] | |||
*Consider [[LP]] (if [[SAH]] or [[meningitis]]/[[encephalitis]] is suspected) | |||
*Consider [[EKG]] if cardiac origin not ruled out | |||
{{Head CT seizure}} | {{Head CT seizure}} | ||
==Management== | ==Management== | ||
{{Seizure actively seizing management}} | |||
===Post-Seizure=== | |||
''Several states have mandatory DMV reporting requirements'' | |||
*No [[anticonvulsant]] treatment necessary if patient has<ref name="Guideline">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 | |||
==Disposition== | ==Disposition== | ||
*Discharge (no need to start antiepileptic<ref name="Guideline"></ref>) with neuro follow up | |||
**Risk for recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%) | |||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Neurology]] |
Revision as of 22:51, 1 October 2019
Background
Seizure Types
Classification is based on the international classification from 1981[1]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[2]
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[3]
- 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
- Temporary focal deficit up to 36 hr post-seizure
- Lateral tongue biting - 100% specificity
- Incontinence
Differential Diagnosis
Causes of 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)
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Evaluation
Work-up
- POC glucose
- CBC
- Chemistry
- Pregnancy test (female)
- Urine toxicology screen
- Consider LP (if SAH or meningitis/encephalitis is suspected)
- Consider EKG if cardiac origin not ruled out
Indications for Head CT due to Seizure[4]
- If patient has returned to a normal baseline:
- When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure
- Deferred outpatient neuroimaging may be used when reliable follow-up is available
Management
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)[5]
- Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[6]
- 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[7]
- 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 [8]
- Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[6]
- Secondary medications
- ESETT trial[9] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [10] which is Levetiracetam
- Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)[11]
- Phenytoin IV 18 mg/kg at ≤ 50 mg/min (avoid in pregnancy)[12]
- 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)[13]
- 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[14]
- Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[15]
- Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[16]
- 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)[17]
- Others
- Carbamazepine 8 mg/kg oral suspension, single oral load
- Gabapentin 900 mg/day oral at 300 mg tid for 3 days
- Lamotrigine 6.5 mg/kg single oral load
Other Considerations
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
Post-Seizure
Several states have mandatory DMV reporting requirements
- No anticonvulsant treatment necessary if patient has[18]:
- 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
Disposition
- Discharge (no need to start antiepileptic[18]) with neuro follow up
- Risk for recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%)
See Also
External Links
References
- ↑ 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.
- ↑ Epilepsia 2015; 56:1515-1523.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
- ↑ 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.
- ↑ 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.
- ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
- ↑ 18.0 18.1 Krumholz A, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology 2015; 84(16):1705-1713.