Seizures and Status Elepticus

Question 1

Classification of seizures

Answer 1

Seizures result from abnormal, excessive activity of the CNS and are categorized as either generalized, involving both hemispheres of the brain with loss of consciousness, or focal (partial), in which only one hemisphere is involved. Focal seizures are referred to as simple partial seizures when cognition is not impaired and as complex partial seizures when cognition is impaired. Focal seizures may generalize to involve both cerebral hemispheres, referred to as partial seizure with secondary generalization.

Question 2

Presentation of seizures

Answer 2

• Most seizures last 1-2 minutes
• Confused for several minutes before they returned back to baseline (postictal state)
• Most common: postictal confusion that resolves while in the ED, evidence of tongue trauma from biting, and urinary or bowel incontinence.

Question 3

Indications for other causes of seizure that are not the primary etiology

Answer 3

Patients may also have tachycardia, diaphoresis, tremulousness, and/or anxiety. These findings may suggest alcohol withdrawal, drug use, or hypoglycemia as possible causes of seizure.

Question 4

What is status epileptics?

Answer 4

• Status epilepticus is present in any patient with a seizure of greater than 5 minutes duration, or 2 or more seizures in a row without a return to baseline.
• Physical exam may reveal a twitching/seizing limb, but absence of visible convulsions does not rule out ongoing seizure activity in the patient with a depressed mental status

Question 5

Patients with a primary seizure disorder are more prone to seize in the setting of:

Answer 5

Medical noncompliance (most common cause of recurrent seizure)
Sleep deprivation
Emotional or physical stress

Question 6

Etiologies of secondary, or reactive, seizures include:

Answer 6

Hypoglycemia (most common cause of reactive seizure)
Hyponatremia
Alcohol withdrawal
Trauma
Drugs/Toxins
Tumor
Infection (e.g., meningitis, encephalitis, CNS abscess)
Eclampsia

Question 7

Diagnoses that mimic seizures:

Answer 7

Pseudoseizure

Syncope

Question 8

For new-onset, first-time seizure, the only lab values routinely recommended

Answer 8

chemistry panel (for sodium and glucose) and a pregnancy test.

Question 9

Labs for patients with status epilepticus

Answer 9

Patients in status epilepticus should receive a more complete laboratory profile including LP to identify possible underlying causes.

Question 10

When to get a CT?

Answer 10

• Every patient with a new-onset seizure should undergo head CT to rule-out intracranial lesions.
• Patients with recurrent seizures should undergo head CT scan if they have a change in their seizure pattern
• All patients in status epilepticus should undergo head CT once stabilized.

Question 11

When should an LP be done?

Answer 11

LP should be considered for any patient with status epilepticus, severe headache, fever, persistent altered mental status, or immunocompromised state (especially HIV). Head CT scan should be performed prior to LP to rule out an intracranial lesion that may cause herniation during LP.

Question 12

When to get an MRI?

Answer 12

Every patient with a new-onset, first-time seizure should receive an MRI as part of their work-up, but this is typically done in the outpatient setting.

Question 13

When to get an EEG?

Answer 13

All patients with a new-onset, first-time seizure should also receive an EEG as part of their outpatient work-up.

Patients in status epilepticus need emergent, continuous EEG monitoring to ensure that they are truly no longer seizing.

Question 14

Alcohol withdrawal seizures

Answer 14

Patients that present with seizures from alcohol withdrawal (delirium tremens) may present with anxiety, tremulousness, and altered mental status. Patients in alcohol will have abnormal vital signs including tachycardia, hypertension, hyperthermia and tachypnea. This is predominantly a clinical diagnosis. An elevated blood alcohol level does not rule out this diagnosis as chronic alcoholics may seize at any blood level.

Question 15

Eclampsia

Answer 15

Clues to the diagnosis include vision complaints, edema of the face, hands, and feet, proteinuria on urine analysis, and hypertension.

Question 16

Toxin induced seizures

Answer 16

In any patient being treated for tuberculosis, suspect isoniazid-induced seizures. Patients with a history of depression may have overdosed on tricyclic antidepressants (look for a widened QRS and prominent terminal R wave in aVR on EKG).

Question 17

Pseudo-seizure

Answer 17

Nevertheless, clues to this diagnosis include a rhythmic, controlled shaking activity, ability to talk or follow commands during the seizure, recall of a seizure that involves both sides of the body, or lack of a postictal period. EEG monitoring is helpful in assessing for pseudoseizure, but is frequently not available in the ED setting.

Question 18

Treatment of seizure

Answer 18

General treatment principles that apply to all seizure patients include management of the ABC’s and supplemental oxygen. Keep the patient safe from falling or other injuries and remove restrictive clothing. Do not place anything in the patient’s mouth except possibly a bite block or oropharyngeal airway to protect the tongue.

First line: benzodiazepines (usually lorazepam)
Second line: fosphenytoin/phenobarbital/valproic acid
Third line: versed/pentobarbital/propofol infusions

Question 19

Common dosages of bentos

Answer 19

A common dose of benzodiazepines is 2 mg of lorazepam or midazolam (5 mg of diazepam) every 2-5 min until seizures are controlled.
Give IV if possible!

Common Medication Dosing

Lorazepam/midazolam: 2 mg PO/IM/IV q 2-5 min as needed
Diazepam: 5 mg PO/IV/IM q 2-5 min as needed (also available PR)
Phenytoin: 15-20 mg/kg PO/IV
Fosphenytoin: 15-20 phenytoin equivalents/kg IV
Phenobarbital: 20 mg/kg IV (use single dose of 60-120 mg PO for oral load)
Valproic acid: 15-45 mg/kg IV

Question 20

Other treatments

Answer 20

Patients in status epilepticus will usually need to be intubated to control the airway.

Some etiologies of seizure have specific treatments:

Eclampsia – Magnesium sulfate
Hyponatremia – Hypertonic saline
Isoniazid – Pyroxidine
Hypoglycemia – Dextrose

Question 21

Restrictions if you suspect someone has had a seizure

Answer 21

Patients should be warned to avoid engaging in activities where they or others would be at risk if they had another seizure (e.g., swimming or bathing alone, cooking with open fire, driving, etc) until they have been cleared to return to these activities.