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1. APPROACH TO SEIZURE
DISORDER
Dr. Jeetendra Bhandari
Medical Officer
Department of Emergency Medicine
CMCTH

2. Introduction
• Paroxysmal alteration of behavior and/ or EGG changes resulting from
abnormal , excessive activity of neuron

3. Some terminology
• Aura
• Pre seizure state characterized by drowsiness, alteration of mood, memory,
perception of hallucination(sound, smell, test, vision, emotion or visceral
sensation)
• Post ictal state
• Period of transition from the ictal state back to the individual's normal level of
awareness and function following end of seizure
• Signifies the recovery period for brain
• Include confusion and suppressed alertness
• Lasts for seconds to minutes to hours

4. • Post ictal paresis/todd’s paralysis
• Transient neurologic deficit that lasts for hours or rarely days after an
epileptic seizure
• Weakness of a hand, arm, or leg
• Weakness could be moderate to severe
• Status epilepticus
• continuous or intermittent seizure activity
• Greater than 5-10 minutes
• Without regaining of consciousness
• Epilepsy
• Recurrent, unprovoked seizures from known or unknown causes

5. Types
• Focal/ partial seizure
• Simple partial seizure
• Complex partial seizure
• Generalized seizure
• Absence
• Tonic
• Clonic
• Tonic clonic
• Atonic
• Myoclonic
• Status epilepticus

6. Focal /partial seizure
• Simple partial seizure
• Simply auras
• seizures that affect enough of the brain to cause symptoms, but not enough
to interfere with consciousness
• Symptoms vary from one patient to another (depend where seizure
originates) brain
• occipital cortex flashing lights, motor cortex rhythmic jerking movements
of different contralateral body parts
• If first seizure in any patient is not followed by auras then it is not likely
epilepsy

7. • Complex partial seizure
• Starts focally in the brain
• Consciousness and awareness of surroundings are lost
• Patients appears awake but are not in orientation to time place and person
• Repetitive behaviors(automatisms) seen
• Usually last less than 3 minutes

8. Generalized seizure
• appear to originate in all regions of the cortex simultaneously
• Absence seizure:
• Sudden brief( few second) lapses of consciousness without falling down
• Tonic
• muscle stiffening
• Clonic
• muscle jerking
• Tonic clonic
• Main seizure type in both epilepsy and other seizure
• Occurs without warning

9. • Atonic
• Sudden loss of postural muscle tone(1-2 second)
• Brief loss of consciousness
• No post ictal state
• Myoclonic
• Sudden and brief muscle contraction

10. Causes
• Primary seizure disorder
• Medical non compliance
• Systemic derangement causing
disrupt in absorption,
distribution and metabolism of
drug
• Structural
• Trauma
• Intracranial hemorrhage
• Infection(meningitis,
encephalitis, brain abscess)
• Neurocysticercosis, malaria
• Increased ICP
• Metabolic Disorder
• Hypo/hyper glycemia
• Hypo/hypernatremia
• Hypocalcemia
• Hypomagnesemia
• Toxins/drugs
• Alcohol withdrawal
• Cocaine
• Isoniazid
• theophylline

12. Where we all fail

13. How to differentiate seizure and syncope?
Seizure Faint (or syncope)
Aura(eg. Olfactory) present Absent
Cyanosis present Absent
Tongue biting present Absent
Post ictal confusion and
amnesia
present Absent
Rapid recovery Absent present
Clear precipitating event(e.g
pain, stress, straining during
micturition or defecation)
Absent present

14. history
• Precipitating event
• Feeling of light headedness just before the faint
• Gradual loss of consciousness
• Presence of an aura
• Prolonged duration of seizure (may suggest conversion disorder)
• Recovery time (usually quick in syncope)
• Tongue biting (never occurs in syncope)
• Injury during fall (rare in syncope and conversion disorder)
• Incontinence of urine (may occur in syncope as well as true seizure, but very rare
in conversion disorder)
• Limb stiffening and twitching (can occur in all pseudo seizures as well as true
seizure)

15. • Timing of Seizure
• Seizure occurs in the presence of others, not when alone (suggests conversion
disorder)
• Brief jerking movements soon after falling asleep (benign sleep myoclonus)
• Angry child who is having a temper tantrum and holds their breath before
seizure occurs (breath-holding attack)
• History of family conflict or stressful circumstances (suggests
conversion disorder)
• Association with exertion (suggests cardiac syncope)
• Palpitations

16. Physical examination
• Presence or absence of tongue biting
• Urinary incontinence
• Presence of post-ictal state (suggests true seizure)
• Hypotension, sweating, clamminess (suggests vasovagal syncope but may
also be cardiac)
• Pulse, bradycardia or tachyarrhythmia
• Abnormal seizure movements (suggestive of conversion disorder not
seizure):
• Elaborate arching of back
• Pelvic thrusting
• Wild flailing of limbs

17. If patient is having seizure during
presentation
• Primary survey
• A = Airway with cervical spine( keep in lateral position)
• B = Breathing( keep on supplemental oxygen)
• C = Circulation( access for iv line)
• D = Disability
• E = Exposure

18. If not with seizure
• Temperature: May be raised in infective causes and in alcohol
withdrawal
• Focal Neurological Signs: Peripheral weakness, Altered sensation,
altered reflexes
• Blood pressure (Hypertensive encephalopathy, Cerebrovascular
attack)
• Signs of raised intracranial pressure: Papilloedema (Fundoscopy),
bradycardia, hypotension, lateral gaze palsy

19. • Bulging anterior fontanelle (in children < 18 months old), shows
raised ICP
• Check head circumference in children
• Dysmorphic features, hepatosplenomegaly and failure to thrive
suggests inborn error of metabolism in children
• Neurocutaneous markers of disease (e.g. Ashleaf macule in tuberous
sclerosis, haemangiomas)

20. Investigation
• Bedside dextrostix (glucose test)
• CBC
• Electrolytes (sodium, potassium)
• Calcium, magnesium
• Blood sugar
• Liver and renal function tests
• Toxicology screen

21. • CT scan with contrast (or MRI) for space occupying lesion
• Electroencephalogram (EEG) to identify the type of epilepsy (normal
EEG does not exclude epilepsy)
• Lumbar puncture if suspect meningitis based on clinical findings and
CBC
• CXR or USG – if suspect malignancy, to look for primary malignancy
with secondary spread to brain

22. Medicine to consider
• Benzodiazepine
• Phenytoin
• Phenobarbital
• Prpofol

23. Benzodiazepine
• For current seizure
• Diazepam 10mg(0.25 mg/kg in paeds) IV over 1 minutes (max 50-8-
mg in adult)
• Lorazepam2 mg(0.1mg/ kg in paeds) IV over 1minutes(max 8 mg in
adults)
• Midazolam 2mg(0.1 mg/kg in paeds) IV ( max dose of 8 mg in adults)
• Duration of action of lorazepam longer than other 2 agents

24. Phenotoin
• Initial dose 20 mg/kg
• Max administration 1mg/kg/min
• Rarely stops current seizure ( mainly to stop recurrent seizure)
• After loading dose, maintenance dose of 300 mg/ hour
• Remember
• Has no role in drug induced seizure

25. Phenobarbital
• Initial dose 20 mg/kg
• Max 1 mg/kg/min(50mg/min)
• Preferred in patient aged 1-2 years(upto 5 years)
• Potential side effects:
• Decreased LOC
• Apnea
• hypotension

26. Propofol
• Usually not used
• Can be used in status epilepticus at standard dose
• Adult: 50 mg bolus followed by infusion of 0-300 mg/hr
• Paed: 1-2 mg/kg bolus followed by 1-10 mg/kg/hour
• Most of patient need intubation at this dose

27. Most important note
• Always avoid paralytics
• Only stop outward manifestation, but
• Do not stop brain from seizing
• Do not fix underlying etiology
• Do not improve mortality
• But paralytics can help
• To facilate intubation
• Facilate CT study
• Facilate surgical procedure

28. For eclampsia
• Magnesium sulphate is drug of choice
• Should be continued after 24hoursoflast seizure or after delivery
• The regimen calls for using:
• 0 hr dose of 4g 20% concentration MgSO4 IV, followed by 10g 50% MgSO4
given IM.
• A maintenance dose of 50% MgSO4 is given 4 hourly.

29. Reference
• PAHS ED protocol 3rd edition. Department of general practice and
emergency medicinepage:123-5.
• Harrison’s Principles of Internal Medicine 18th edition chapter 369 p
3251-68.
• Toronto notes 2016. seizure. Page ER25.
• uptodate ver 21.3. Evaluation of first seizure in adult.

30. Thank you
Have a good day