approach to seizures In Emergency Department

1. APPROACH TO
SEIZURES
Dr. HIRASH
MBBS, MD
SPECIALIST EMERGENCY
MEDICINE

2. INTRODUC
TION

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

4. Status epilepticus: -
 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 <lyr and >60 yr of age
 At least 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

5. ETIOLOG
Y

6.  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

7. SIGNS AND
SYMPTOMS

8.  Altered level of consciousness
 Involuntary repetitive muscle movements: -Tonic posturing or clonic
jerking in Seizures of abrupt onset
 Aura may precede a focal seizure
 Duration usually 90-120 sec
 Impaired memory of the event
 Post-ictal state; 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)

10. History
 History of seizures
 Medication compliance
 Recent illness
 Head trauma
 Headache
 Anticoagulation therapy
 Fever
 Neck stiffness
Physical-Examination
 Complete neurologic examination
 Todd paralysis
 Complete secondary and tertiary survey to evaluate for any trauma
secondary to seizure or potential cause for seizure

11.  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
 Electrolytes including calcium, phosphorus
 Head CT
 Toxicology screen
 Pregnancy test if woman is of child-bearing age

12.  Lumbar puncture indicated if:
 New-onset seizure with fever
 Severe headache
 Immuno compromised state
 Persistently altered mental state

13.  Pediatric Considerations
 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
 appearing Lethargic or poor feeding
 Unreliable follow-up

14. LABORATORY
INVESTIGATIONS

15.  Blood-
 alcohol level
 Toxicology screen
 CBC: -WBC often elevated
 Bio Chemistry panel: Bicarbonate often low, Lactate
may be elevated
 CSF: May have transient increase in WBC to 20/uL

16.  Imaging
 Noncontrast CT head :
 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

17.  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

18. DIFFERENTIAL DIAGNOSIS
 Syncope (may also have incontinence,twitching, and jerking)
 Hyperventilation syndrome
 Psychogenic seizures
 Transient ischemic attacks
 Sleep disorders
 Delirium tremens
 Hypoglycemia

19. TREATMEN
T

20.  PRE HOSPITAL
 Anticonvulsants as per local protocol
 INITIAL STABILIZATION/THERAPY
 Airway management as indicated
 Pulse oximetry,
 oxygen and suction if indicated
 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

21.  ED TREATMENT/PROCEDURES
 1st-time seizure: -Normal head CT, Return to baseline with normal
neurological exam: Discharge with close follow-up with neurologist
 1st-time seizure: -Structural lesion on CT or MRI  Start
antiepileptic drug (AED) in consultation with neurologist
 Recurrent seizure not on AED  Start AED in consultation with
neurologist
 Recurrent seizure with subtherapeutic AED level  load current
AED IV and/or PO
 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

22.  Seizure in a pregnant patient:
Evaluate as other seizure patients
Strongly consider eclampsia if > 20-wk gestation-OBG
consultation,arrange for C-section
Magnesium sulphate
 Seizures related to alcohol: -Determine if seizure is caused by
withdrawal (typically 6-48 hrs after cessation of drinking) or
another cause
Management of withdrawal seizures is benzodiazepines

23.  Pediatric Considerations
 Fever control with acetaminophen and ibuprofen
 Anticonvulsants not needed for febrile seizures
 Anticonvulsants should be prescribed in conjunction with
neurologist.

24. PHARMACOLO
GY

25.  Acetaminophen:500 mg PO/PR q46h; 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 ; at rate of 100-150 mg/min
 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 ug/kg/min IV, titrate to effect (plan to protect airway)
 Valproatesodium: 10-20 mg/kg

26.  First Line
 Benzodiazepines
 Second Line
 Fosphenytoin
 Levetiracetam
 Phenobarbital
 Phenytoin
 Propofol
 Valproate sodium

27. FOLLOW UP AND
DISPOSITION

28.  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

29.  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

30. THANK YOU