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Seizure, Adult, Emergency Medicine

Basics

Description

- Generalized seizures: - Classically tonic " clonic (grand mal) - Begin as myoclonic jerks followed by loss of consciousness - Sustained generalized skeletal muscle contractions - Nonconvulsive generalized seizures: - Absence seizures (petit mal); alteration in mental status without significant convulsions or motor activity

- Complex: - Mental and psychological symptoms - Affect changes - Confusion - Automatisms - Hallucinations - Associated with impaired consciousness

- At least one-half of patients presenting to the ED in status do not have a history of seizures. - Alcohol withdrawal seizures ( "rum fits " ): - Peak within 24 hr of last drink - Rarely progress to status epilepticus

- Structural: - Primary or metastatic neoplasm - Degenerative disease (i.e., multiple sclerosis) - Scar from previous trauma

- Duration usually 90 " 120 sec: - Impaired memory of the event - Postictal state is a brief period of confusion and somnolence following a seizure

- Evidence of recent seizure activity: - Confusion or somnolence - Acute intraoral injury - Urinary incontinence - Posterior shoulder dislocation - Temporary paralysis (Todd paralysis)

- A thorough history is the most valuable part of the workup: - Witness accounts - History of prior seizures - Presence of acute illness - Past medical problems - History of substance use

- Patients with chronic seizure disorder and typical seizure pattern may need to have only serum glucose and anticonvulsant levels checked - New-onset seizure mandates workup: - Electrolytes including calcium, phosphorus - Head CT - Toxicology screen - Pregnancy test if woman is of childbearing age - Lumbar puncture indicated if: - New-onset seizure with fever - Severe headache - Immunocompromised state

- A child with a 1st febrile seizure should receive fever workup as dictated by clinical condition - Inquire about family history of febrile seizures - Labs and radiographs as needed to determine source of fever - Lumbar puncture for 1st febrile seizure: - Consider if age <1 yr - Ill appearing - Lethargy or poor feeding - Exam difficult - Unreliable follow-up

- Seizure in a pregnant patient: - Evaluate as other seizure patients - Strongly consider eclampsia if >20-wk gestation - OB consultation, arrange for C-section - Magnesium

  • Generalized seizures:Classically tonic " clonic (grand mal)Begin as myoclonic jerks followed by loss of consciousnessSustained generalized skeletal muscle contractionsNonconvulsive generalized seizures:Absence seizures (petit mal); alteration in mental status without significant convulsions or motor activity
  • Partial seizures:Simple:Brief sensory or motor symptoms without loss of consciousness (i.e., Jacksonian)Complex:Mental and psychological symptomsAffect changesConfusionAutomatismsHallucinationsAssociated with impaired consciousness
  • Status epilepticus:Variable definitions:Seizure lasting longer than 5 " 10 minRecurrent seizures without return to baseline mental status between eventsLife-threatening emergency with mortality rate of 10 " 12%Highest incidence in those <1 yr and >60 yr of age
  • At least one-half of patients presenting to the ED in status do not have a history of seizures.
  • Alcohol withdrawal seizures ( "rum fits " ):Peak within 24 hr of last drinkRarely progress to status epilepticus
  • Patients with a single seizure have a 35% risk of recurrent seizure within 5 yr

Febrile seizures are generalized seizures occurring between 3 mo and 5 yr of age:

  • Typically lasts <15 min
  • Associated with a rapid rise in temperature
  • Without evidence of CNS infection or other definitive cause

Etiology

  • Hypoxia
  • Hypertensive encephalopathy
  • Eclampsia
  • Infection:MeningitisAbscessEncephalitis
  • Vascular:Ischemic strokeHemorrhagic strokeSubdural hematomaEpidural hematomaSubarachnoid hemorrhageArteriovenous malformation
  • Structural:Primary or metastatic neoplasmDegenerative disease (i.e., multiple sclerosis)Scar from previous trauma
  • Metabolic:ElectrolytesHypernatremiaHyponatremiaHypocalcemiaHypo/hyperglycemiaUremia
  • Toxins/drugs:LidocaineTricyclic antidepressantsSalicylatesIsoniazidCocaineAlcohol withdrawalBenzodiazepine withdrawal
  • Congenital abnormalities
  • Idiopathic
  • Trauma

Diagnosis

Signs and Symptoms

  • Altered level of consciousness
  • Involuntary repetitive muscle movements:Tonic posturing or clonic jerking
  • Seizures of abrupt onset:Aura may precede a focal seizure
  • Duration usually 90 " 120 sec:Impaired memory of the eventPostictal state is a brief period of confusion and somnolence following a seizure
  • Evidence of recent seizure activity:Confusion or somnolenceAcute intraoral injuryUrinary incontinencePosterior shoulder dislocationTemporary paralysis (Todd paralysis)
  • Other findings may suggest etiology of seizure:Fever and nuchal rigidity (CNS infection)Needle tracks; stigmata of liver disease (drugs and alcohol)Head trauma:Papilledema (increased intracranial pressure)Lateralized weakness, sensory loss, or asymmetric reflexes

History

  • History of seizures:
  • Recent illness
  • Head trauma
  • Headaches
  • Anticoagulation therapy
  • Fever
  • Neck stiffness

Physical Exam

  • Complete neurologic exam:
  • Complete secondary and tertiary survey to evaluate for any trauma secondary to seizure or potential cause for seizure

Essential Workup

  • A thorough history is the most valuable part of the workup:Witness accountsHistory of prior seizuresPresence of acute illnessPast medical problemsHistory of substance use
  • Patients with chronic seizure disorder and typical seizure pattern may need to have only serum glucose and anticonvulsant levels checked
  • New-onset seizure mandates workup:Electrolytes including calcium, phosphorusHead CTToxicology screenPregnancy test if woman is of childbearing ageLumbar puncture indicated if:New-onset seizure with feverSevere headacheImmunocompromised state
  • Persistently altered mental state:Search for specific underlying causePatients condition and resources for follow-up determine whether all these tests must be done in the ED
  • A child with a 1st febrile seizure should receive fever workup as dictated by clinical condition
  • Inquire about family history of febrile seizures
  • Labs and radiographs as needed to determine source of fever
  • Lumbar puncture for 1st febrile seizure:Consider if age <1 yrIll appearingLethargy or poor feedingExam difficultUnreliable follow-up

Diagnosis Tests & Interpretation

Lab

  • Serum anticonvulsant levels
  • Blood " alcohol level
  • Toxicology screen
  • CBC:
  • Chemistry panel:
  • Lactate may be elevated
  • CSF:May have transient increase in WBC to 20/ ΌL

Imaging

  • Noncontrast head CT:Persistent or progressive alteration of mental statusFocal neurologic deficitsSeizure associated with trauma
  • CT scan with contrast should be obtained in HIV-positive patients to rule out toxoplasmosis
  • MRI is sensitive for low-grade tumors, small vascular lesions, early inflammation, and early cerebral infarcts:Consider electively in new-onset seizures

Diagnostic Procedures/Surgery

  • EEG may be arranged with neurology on an outpatient basis
  • Bedside EEG may be performed in ED if there is suspicion of nonconvulsive status epilepticus or psychogenic seizures

Differential Diagnosis

  • Syncope (may also have incontinence, twitching, and jerking)
  • Hyperventilation syndrome
  • Psychogenic seizures
  • Transient ischemic attacks
  • Sleep disorders
  • Delirium tremens
  • Hypoglycemia

Treatment

Pre-Hospital

Anticonvulsant as per local protocol

Initial Stabilization/Therapy

  • Airway management as indicated
  • Pulse oximetry, oxygen with suction available:C-spine precautionsRapid-sequence intubation if patient cannot protect airway or with hypoxia or major head traumaIV access, rapid determination of serum glucose:If hypoglycemic, give IV dextrose 25 gLorazepam or diazepam for active seizuresNaloxone if concern for narcotic overdose

Ed Treatment/Procedures

  • 1st-time seizure:Normal head CT if performedReturn to baseline with normal neuro exam:Discharge with close follow-up with PCP and/or neurologist
  • 1st-time seizure:Structural lesion on CT or MRI:Start antiepileptic drug (AED) in consultation with PCP and/or neurologist
  • Recurrent seizure not on AED:Start AED in consultation with PCP and/or neurologist
  • Recurrent seizure with subtherapeutic AED level:IV and/or PO load current AED
  • Recurrent seizure with therapeutic AED level:Need careful evaluation for cause of seizures, new lesions, etc.:Adjust and/or add AED in consultation with neurologist
  • Seizure in a pregnant patient:Evaluate as other seizure patientsStrongly consider eclampsia if >20-wk gestationOB consultation, arrange for C-sectionMagnesium
  • Seizures related to alcohol:Determine if seizure is caused by withdrawal (typically 6 " 48 hr after cessation of drinking) or another causeManagement of withdrawal seizures is benzodiazepines
  • Fever control with acetaminophen and ibuprofen
  • Anticonvulsants not needed for febrile seizures
  • Anticonvulsants should be prescribed in conjunction with neurologist.

Medication

  • Acetaminophen: 500 mg PO/PR q4 " 6h; do not exceed 4 g/24 h
  • Diazepam: 0.2 mg/kg IV per dose; 0.5 mg/kg PR
  • Fosphenytoin: 15 " 20 mg/kg phenytoin equivalents (PE) at rate of 100 " 150 mg/min IV/IM
  • Ibuprofen: 5 " 10 mg/kg PO
  • Levetiracetam: Start 500 mg PO/IV q12h (peds: Start 20 mg/kg/d PO div. BID; age 4 " 15 yr)
  • Lorazepam: 2 " 4 mg IV/IM (peds: 0.05 " 0.1 mg/kg IV per dose)
  • Naloxone: 0.4 " 2 mg IV/IM/SQ (peds: 0.1 mg/kg IV/IM/SQ)
  • Phenobarbital: 15 " 20 mg/kg IV at rate of 1 mg/kg/min (plan to protect airway)
  • Phenytoin: 15 " 20 mg/kg IV at rate of 40 " 50 mg/min (peds: Use rate of 0.5 " 1 mg/kg/min)
  • Propofol: 5 " 50 Όg/kg/min IV, titrate to effect (plan to protect airway)
  • Valproate sodium: 10 " 20 mg/kg/d

First Line

Benzodiazepines

Second Line

  • Fosphenytoin
  • Levetiracetam
  • Phenobarbital
  • Phenytoin
  • Propofol
  • Valproate sodium:works as well as second line agent in status epilepticus and can be given faster

Follow-Up

Disposition

Admission Criteria

  • Patients with status epilepticus should be admitted to the ICU
  • Patients with seizures secondary to underlying disease (e.g., meningitis, intracranial lesion) must be admitted for appropriate treatment and monitoring
  • Patients with poorly controlled repetitive seizures should be admitted for monitoring
  • Delirium tremens

Discharge Criteria

  • Patient with normal workup and appropriate neurology follow-up
  • Uncomplicated seizure in patient with chronic seizure disorder
  • Seizure secondary to reversible cause:Hypoglycemia if blood sugar has stabilizedAlcohol withdrawal if baseline mental status and no further seizures
  • Simple febrile seizure

Issues for Referral

  • Consider early neurology follow-up
  • Anticonvulsant drug level monitoring

Followup Recommendations

No driving until seizures are under control

Pearls and Pitfalls

  • Most common cause of recurrent seizure is subtherapeutic anticonvulsant drug level
  • Benzodiazepines are the 1st-line treatment to stop seizure activity
  • Treat the underlying cause if identifiable
  • Seizures lasting longer than 5 " 10 min should be treated as status epilepticus
  • Valproate likely works as well as phenytoin/fosphenytoin as a second line agent in treating status epilepticus and can be administered more quickly with less chance of an adverse effect

Additional Reading

  • ACEP Clinical Policies Subcommittee (Writing Committee) on Seizures; Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63:437 " 447.
  • French JA, Pedley TA. Clinical practice. Initial management of epilepsy. N Engl J Med. 2008;359:166 " 176.
  • Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure. Emerg Med Clin North Am. 2011;29:41 " 49.
  • Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007;69:1996 " 2007.

See Also (Topic, Algorithm, Electronic Media Element)

  • Headaches
  • Hypertensive Emergencies
  • Intracerebral Hemorrhage
  • Preeclampsia/Eclampsia
  • Seizure, Febrile
  • Seizure, Pediatric

Codes

ICD9

  • 345.00 Generalized nonconvulsive epilepsy, without mention of intractable epilepsy
  • 345.90 Epilepsy, unspecified, without mention of intractable epilepsy
  • 780.39 Other convulsions
  • 345.3 Grand mal status
  • 345.10 Generalized convulsive epilepsy, without mention of intractable epilepsy
  • 345.50 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy

ICD10

  • G40.009 Local-rel idio epi w seiz of loc onst, not ntrct, w/o stat epi
  • G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
  • R56.9 Unspecified convulsions
  • G40.901 Epilepsy, unsp, not intractable, with status epilepticus

SNOMED

  • 91175000 seizure (finding)
  • 246545002 Generalized seizure (finding)
  • 54200006 Tonic-clonic seizure (finding)
  • 230456007 Status epilepticus (disorder)
  • 29753000 Partial seizure (disorder)
  • 79631006 Absence seizure (disorder)