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
Partial seizures:
- Simple:
  - Brief sensory or motor symptoms without loss of consciousness (i.e., Jacksonian)
- Complex:
  - Mental and psychological symptoms
  - Affect changes
  - Confusion
  - Automatisms
  - Hallucinations
  - Associated with impaired consciousness
Status epilepticus:
- Variable definitions:
  - Seizure lasting longer than 5 " 10 min
  - Recurrent seizures without return to baseline mental status between events
- Life-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 drink
- Rarely 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:
- Meningitis
- Abscess
- Encephalitis
Vascular:
- Ischemic stroke
- Hemorrhagic stroke
- Subdural hematoma
- Epidural hematoma
- Subarachnoid hemorrhage
- Arteriovenous malformation
Structural:
- Primary or metastatic neoplasm
- Degenerative disease (i.e., multiple sclerosis)
- Scar from previous trauma
Metabolic:
- Electrolytes
- Hypernatremia
- Hyponatremia
- Hypocalcemia
- Hypo/hyperglycemia
- Uremia
Toxins/drugs:
- Lidocaine
- Tricyclic antidepressants
- Salicylates
- Isoniazid
- Cocaine
- Alcohol withdrawal
- Benzodiazepine 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 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)
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:
- Medication compliance
Recent illness
Head trauma
Headaches
Anticoagulation therapy
Fever
Neck stiffness

Physical Exam

Complete neurologic exam:
- Todd paralysis
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 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
Persistently altered mental state:
- Search for specific underlying cause
- Patients 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 yr
- Ill appearing
- Lethargy or poor feeding
- Exam difficult
- Unreliable follow-up

Diagnosis Tests & Interpretation

Lab

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

Imaging

Noncontrast head CT:
- Persistent or progressive alteration of mental status
- Focal neurologic deficits
- Seizure 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 precautions
- Rapid-sequence intubation if patient cannot protect airway or with hypoxia or major head trauma
- IV access, rapid determination of serum glucose:
  - If hypoglycemic, give IV dextrose 25 g
- Lorazepam or diazepam for active seizures
- Naloxone if concern for narcotic overdose

Ed Treatment/Procedures

1st-time seizure:
- Normal head CT if performed
- Return 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 patients
- Strongly consider eclampsia if >20-wk gestation
- OB consultation, arrange for C-section
- Magnesium
Seizures related to alcohol:
- Determine if seizure is caused by withdrawal (typically 6 " 48 hr after cessation of drinking) or another cause
- Management 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 stabilized
- Alcohol 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.

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)

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