Seizure

Question 1

A 22 year old woman is brought to ED after having her first generalised seizure. She is slightly confused. How would you assess and manage her?

Answer 1

Impression
Presentation post first seizure, in what clinically appears to be a post-ictal phase.

In this setting there are several important aetiologies of seizure to consider;

• Vascular: stroke, ICH, other form of haemorrhage
• Infective: meningitis, abscess, encephalitis
• Neoplastic: SOL
• Electrolytes: hypoglycaemia, hypo/hyperK, Ca, Na
• Medications/drugs: steroids,
• Mimics: syncope,
• Primary epilepsy syndrome

Goals

• Assess taking A to E approach to rule out HD instability, any continuing/recurring seizure activity, utilise status pathway for acute management if indicated
• take concurrent Hx/Ex/Ix
• supportively manage in acute setting and appropriately disposition for definitive mx

Question 2

Seizure - Assessment

Answer 2

Assessment
A - Patent, maintaining, tube pending GCS
B - RR/SP02 - supplemental as req
C - BP/HR/ECG monitoring. IVC access, initial bloods (VBG, UEC, BSL, FBC, LFT, CRP/ESR, cultures if febrile). Fluid and electrolyte replacement. Consider anti-epileptic If risk of recurrent seizure acutely.
D - GCS, PEARL, focal neurology
E - Left lateral position, temp

Question 3

Seizure - History

Answer 3

History
- PC: before, during, after for semiology (focal vs general), how long for, witness? (take collateral), any incontincence? sore muscles/bitten tongue?
- Other: recent infective sx, features of malignancy, PMHx for known epilepsy disorder, recent trauma? Features of meningism.
o risks: poor sleep, drug use, psychological stress
- Other: Fam hx,
- Medications: AEDs, allergies
- Psychosocial Hx

Question 4

Seizure - Examination

Answer 4

Examination

• General appearance: post ictal
• Vials
• Full neurological examination, serial
• Resp exam: ?aspiration
• Head to toe for other injuries (Secondary survey)

Question 5

Seizure - Investigations

Answer 5

Investigations

• Bedside: ECG, VBG, urinalysis, BSL, Urine drug screen
• Bloods: FBC, UEC, LFT, CRP/ESR, cultures if septic, pro-calcitonin,
• CT Brain/MRI, video EEG

Question 6

Seizure - Management

Answer 6

Management
Supportive
- electrolyte correction and fluid resus
- left lateral, regular obs
- patient education and counselling:
   o avoid triggers: sleep deprivation, drugs, stress
   o witness when swimming etc
   o Stop driving until definitive cause identified then further advice - law varies state to state but likely return to driving if 6-12 months seizure free
   o provide appropriate info hand outs

Definitive
- referral to Neurologist for further investigation/workup