In a patient having a seizure:
Ensure proper airway control (e.g., oropharyngeal airway or nasal trumpet, lateral decubitus to prevent aspiration).
Use drugs (e.g., benzodiazepines, phenytoin) promptly to stop the seizure, even before the etiology is confirmed.
Rule out reversible metabolic causes in a timely fashion (e.g., hypoglycemia, hypoxia, heat stroke, electrolytes abnormalities).
In a patient presenting with an ill-defined episode (e.g., fits, spells, turns), take a history to distinguish a seizure from other events.
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).
In all patients presenting with a seizure, examine carefully for focal neurologic findings.
In a patient with a previously known seizure disorder, who presents with a seizure or a change in the pattern of seizures:
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).
Include other causes of seizure in the differential diagnosis. (Not all seizures are caused by epilepsy.)
In the ongoing care of a patient with a stable seizure disorder:
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).
Monitor for complications of the anticonvulsant medication (e.g., hematologic complications, osteoporosis).
Modify management of other health issues taking into account the anticonvulsant medication (e.g., in prescribing antibiotics, pregnancy).
See Febrile Seizure
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)
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
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
Vitals, Temperature, Glucose
Complete neuro exam
Lateral tongue biting
Trauma during episode
TIA
Eclampsia
Syncope
Migraine
Cardiac disorders (Dysrhythmias, Long QT syndrome, HOCM)
Sleep disorders (Narcolepsy)
Movement disorder
Acute dystonia
Rigors
Pseudoseizure
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)
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)
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
Neurology Consult
Dangers of swimming, living alone, operating machinery, chewing gum, heights
Seizure free x 1 year before driving
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