Seizures

1. In a patient having a seizure: 

   1. Ensure proper airway control (e.g., oropharyngeal airway or nasal trumpet, lateral decubitus to prevent aspiration).

   2. Use drugs (e.g., benzodiazepines, phenytoin) promptly to stop the seizure, even before the etiology is confirmed.

   3. Rule out reversible metabolic causes in a timely fashion (e.g., hypoglycemia, hypoxia, heat stroke, electrolytes abnormalities).

2. In a patient presenting with an ill-defined episode (e.g., fits, spells, turns), take a history to distinguish a seizure from other events.

3. In a patient presenting with a seizure, take an appropriate history to direct the investigation (e.g., do not overinvestigate; a stable known disorder may require only a drug-level measurement, while new or changing seizures may require an extensive work-up).

4. In all patients presenting with a seizure, examine carefully for focal neurologic findings.

5. In a patient with a previously known seizure disorder, who presents with a seizure or a change in the pattern of seizures: 

   1. Assess by history the factors that may affect the primary seizure disorder (e.g., medication compliance, alcohol use, lifestyle, recent changes in medications [not just antiepileptic medications], other illnesses).

   2. Include other causes of seizure in the differential diagnosis. (Not all seizures are caused by epilepsy.)

6. In the ongoing care of a patient with a stable seizure disorder: 

   1. Regularly inquire about compliance (with medication and lifestyle measures). side effects of anticonvulsant medication, and the impact of the disorder and its treatment on the patient’s life (e.g., on driving, when seizures occur at work or with friends). 

   2. Monitor for complications of the anticonvulsant medication (e.g., hematologic complications, osteoporosis).

   3. Modify management of other health issues taking into account the anticonvulsant medication (e.g., in prescribing antibiotics, pregnancy).

See Febrile Seizure

General Overview

• Generalized: Tonic-clonic (grand mal), absence (petit mal), myoclonic

  • Diffuse motor activity and LOC at onset

• Partial (focal, eg. one extremity)

  • Complex = Consciousness affected

  • Partial = No LOC

• Status epilepticus if >5-15mins or multiple seizures without full return to consciousness

• Pseudoseizure

  • Diffuse motor activity (moving all extremities) with preservation of consciousness (eg. speaking)

  • Eyes squeezed shut (most epileptic patients do not resist eyelid raising)

  • Responsive noxious stimuli (nasal swab)

  • Out-of-phase movement of limbs (usually limbs move synchronously)

  • Unusual movmeents (pelvic thursting, side-to-side head movement)

Management of Status Epilepticus

• Protect airway, oxygen, intubation if unable to terminate seizure

• IV access if possible

• Terminate seizure (prevent brain damage)

  • First-line: Benzodiazepines

    • Lorazepam 0.1mg/kg IV up to max 8mg IV, 

    • Midazolam 10mg IM

    • Diazepam 10mg IV/rectal/ET q5 mins x 3

• r/o hypoglycemia - Glucose 1-2 amps of D50W (25g-50g) IV (can be given empirically if no glucose test available) 

• r/o hyponatremia - 150mL of 3% NaCl (with repeat bolus if persistent seizure) or 2 amps of NaCO3 (100mEq in 100mL)

  • Anti-epileptic for ALL status epilepticus (seizure >5mins):

    • Keppra 60mg/kg IV (up to 4500mg) over 10 minutes

      • Preferred as safe, no contraindications, and minimal side effects (SIADH)

    • Valproic acid 40mg/kg (up to 3000mg) over 10 minutes

    • Fosphenytoin

    • Phenobarbital (usually in alcohol withdrawal)

  • If seizure persists, prepare for intubation

    • Propofol 1.5mg/kg + Ketamine 3mg/kg + Rocuronium 0.6mg/kg (lower dose so that doesn't last too long)

      • Then propofol infusion at 3-5mg/kg/hour (avoid propofol infusion syndrome, keep <5mg/kg/h)

      • Prepare pressors PRN (norepinephrine)

    • If severely hypotensive, consider Midazolam 0.2mg/kg loading dose with 0.1mg/kg/h infusion

  • If seizure persists, consider re-bolus propofol and ketamine or high-dose ketamine 1-2mg/kg q5mins PRN (up to 10mg/kg cumulative dose)

  • Consult neurology, ICU

History

• Seizure disorder

  • Careful history for previous seizures

• Precipitating factors

  • Sleep deprivation, stress

  • Infection

  • Alcohol use/withdrawal, drug use

  • Change in medications

• Localized vs. Generalized/symmetrical

  • Unilateral movements, eye deviation, head turning to one side 

  • Tonic-Clonic - very rigid with extension and then rhythmic jerking

• Duration (usually 60-90 seconds)

• Loss of bowel and bladder control, tongue biting

• Apnea, cyanosis

• Gradual return to consciousness, postictal confusion

Physical Exam

• Vitals, Temperature, Glucose

• Complete neuro exam

• Lateral tongue biting

• Trauma during episode

DDx

• TIA

• Eclampsia

• Syncope

• Migraine

• Cardiac disorders (Dysrhythmias, Long QT syndrome, HOCM)

• Sleep disorders (Narcolepsy)

• Movement disorder

• Acute dystonia

• Rigors

• Pseudoseizure

Causes

• Stroke

• Metabolic / Electrolyte

  • Hypo/hyperglycemia

  • Hypo/hypernatremia

  • Hypophophatemia

  • Hypocalcemia

  • Hyperammonemia/hepatic encephalopathy

  • Uremia

• Hypoxia

• Hyperthermia

• Hypertension (encephalopathy, PRES, eclampsia)

• CNS trauma, tumor, bleed, stroke (ischemic>hemorrhagic), infection (meningitis, encephalitis, abscess)

• Drug intoxication (anticonvulsants, antidepressants, antipsychotics, isoniazid, opioids, theophylline, sympathomimetics)

• Drug withdrawal (alcohol, barbiturates, benzodiazepines)

• Low dilantin (in known epilepsy)

Investigations

• Known seizure

  • Serum anticonvulsant levels

• First seizure

  • Glucose

  • Chem (Sodium, Creat, Calcium, Magnesium, Phos, Urea)

    • Consider LFT, ammonia in cirrhosis

  • B-hCG

  • CBC

  • Consider CK for rhabdo

  • Consider anti-epileptic drug levels (for adherence)

  • Consider toxicology (cocaine, methamphetamine)

  • Head CT generally recommeneded unless obvious cause (non-adherence to anti-epileptic)

    • In children, if <1yo  and in those with cognitive or motor developmental delay, unexplained neurologic abnormalities, a history of focal seizures, or findings on electroencephalography (EEG) that are incompatible with benign partial epilepsy of childhood or primary generalized epilepsy

  • EEG within 24-48h

  • LP if immunosuppressed (r/o meningitis, encephalitis)

Anticonvulsant (eg. Keppra)

• Do not need to start antiepileptic medication in first seizure

  • Consider if risk factor (eg. abnormal EEG results or brain injury/lesion)

    • If no risk factor, counsel on excellent prognosis, and can consider medication if second seizure episode occurs

  • Consider as per patient's preference or work (eg. pilot)

• Anticonvulsants (valproic acid, phenytoin) are teratogenic, advise taking folic acid and be on lowest dose

• Adverse effects: Osteoporosis, hematologic (decreased WBC, pancytopenia), liver failure (phenytoin), GI symptoms, fatigue

• Antibiotics may interfere with anticonvulsant levels

Follow-up

• Neurology Consult

• Dangers of swimming, living alone, operating machinery, chewing gum, heights

  • Seizure free x 1 year before driving