1/5/2010

Seizures

Definitions
Seizure:
abnormal neurologic functioning
caused by abnormally excessive
activation of neurons, either in the
cerebral cortex or in the deep limbic
system

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Status Epilepticus
• “prolonged or repetitive seizures without
intervening neurologic recovery.”also
• “Patients who remain unresponsive to the
third-level choice of pharmacologic
intervention”

• Traditionally: at least 30 min.

• Some experts: ↓ to 5 min.

Epidemiology
• 6% of population, at least one afebrile
seizure during their lifetime
• annual incidence in adults is 84/100,000
population
• 1% of ED visits .
• 25% related to poor compliance to
antiepileptic drugs

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Classification

• Primary vs Secondary

• Generalized vs Focal (Partial)

• Convulsive vs Nonconvulsive

1ry vs 2ry
Primary Secondary
• Intoxication
“epilepsy” • Poisoning
• Encephalitis
• Encephalopathy (HTN, hepatic)
• organ failure
• other metabolic disturbances
• infections of the CNS
• cerebral tumors
• Pregnancy
• supratherapeutic levels of
anticonvulsants

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Febrile Seizures
• most common pediatric seizure
• 2% to 5% of children between 6 months
and 5 years of age
• 20% to 30% of those children have at least
one recurrence
• Is it a febrile seizure, or a seizure with
fever?
REMEMBER:
REMEMBER:
First time seizures in infants younger than 6
months may indicate significant underlying
pathology and warrant a full assessment.

Generalized vs Focal (Partial)

Generalized Partial

• Tonic-Clonic • Simple partial

• Absence • Complex partial
• Myoclonic • 2ry generalized
• Tonic • mixed
• Clonic

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Convulsive vs Nonconvulsive

Pathophysiology
• generalized seizures:
– focus is deep and midline
loss of
consciousness and bilateral involvement.
• self-limited:
– may be related to reflex inhibition, neuronal
exhaustion, or alteration of the local balance of
neurotransmitters
• Partial seizures:
– less recruitment, the ictal activity does not cross
the midline. Because of the more limited focus of
abnormal activity, convulsive motor activity may
not be the predominant clinical manifestation

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Approach
• Is it really a seizure?

• Rapid assessment and stabilization

• History & Examination

• Investigations (labs, CT, EEG)

Is it Really a Seizure?
Syncope Vasodepressive vs dysrhythmogenic vs
orthostatic
hyperventilation
Breath holding
Toxic & • alcohol • ↓glc • PCP • Tetanus
metabolic • Strychnine & camphor • Extrapyramidal rxn
Nonictal CNS • TIA • transient global amnesia • migraine
• carotid sinus hypersensitivity • narcolepsy
Movement • hemiballismus • tics
Psychiatric • Fugue • Panic
Functional pseudoseizure

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Fit vs Faint
• More forceful and Can have:
prolonged • myoclonic activity
• frequent head turns
• upward gaze
• oral automatisms
• righting movements
• post-ictal state (except in
atonic, absence seizures) • no post-ictal state
• retrograde amnesia
• incontinence
• tongue biting

Properties of a Seizure
1. Abrupt onset
2. Brief duration: 90 to 120 seconds
3. Altered mental status: except for simple partial
seizures.
4. Purposeless activity: e.g. automatisms and undirected
tonic-clonic movements.
5. Unprovoked: except fever in children and substance
withdrawal in adults (NOT emotional stimuli)
6. Postictal state: except simple partial and absence;
atypical postictal states include neurogenic pulmonary
edema and Todd's paralysis.

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Rapid Assessment and Stabilization

confirm a pulse!
• IV line
• Glucometer (↓ glc as a cause, result)
• List of medications
• Airway (nasopharyngeal)
• Suction
• Remove dentures
• Protect patient from self injury
• Pulse oximetry + oxygen
• Turn to the side to prevent aspiration
Keep ET tube prepared

Abortive Treatment for Seizures

• Lorazepam: IV , longer t½, alcohol
1st withdrawal
line • Diazepam: PR, ET, IO NOT IM
• Midazolam: IM
Think of
2nd • Adult: phenytion/fosphenytoin (IV/IM) INH OD
line • Ped.: phenobarbital

3rd • Adult: phenobarbital

line • Ped.: phenytion / fosphenytoin (IV/IM)

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Drug Adult Dose Pediatric Dose

Diazepam 0.2 mg/kg IV at 2 mg/min 0.2–0.5 mg/kg IV/IO/ET or
up to 20 mg 0.5–1.0 mg/kg PR up to 20
mg
Lorazepam 0.1 mg/kg IV at 1–2 mg/min 0.05–0.1 mg/kg IV
up to 10 mg
Midazolam 0.15 mg/kg IV, then 2–
0.1 mg/kg given at 1 mg/min up to 10 10 mg/kg/min
mg IV
Phenytoin 20 mg/kg IV at ≤40 mg/min 20 mg/kg IV at 1
0.2 mg/kg IM
mg/kg/min
Fosphenytoin 15–20 mg/kg IV at 100–150 Under investigation
mg/min or 20 mg/kg IM
Phenobarbital 20–30 mg/kg IV at 60–100
mg/min or as single IM
dose
Valproate 20 mg/kg PR or 10–15
mg/kg IV (initial dose)
Pentobarbital 5 mg/kg IV at 25 mg/min,
then titrate to EEG

History
• previous history of diagnosed seizures
• was the reported ictal activity witnessed by a reliable
observer
• intercurrent illness (esp. fever in children)
• trauma
• drug or alcohol use
• potential adverse drug-drug interactions with
anticonvulsants
• medication compliance
• recent change in anticonvulsant dosing regimens
• change in ictal pattern or characteristics
• Sleep deprivation
• Pregnancy
• Travel Hx (cysticercosis, malaria)

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“COLD”
• C : Character (type)

• O : Onset (what was he doing)

• L : Location (focal signs)

• D : Duration

Examination
• Sympathetic stim. (↑hr, ↑bp, ↑ rr, mild ↑ T)
• Sk. m. damage, lactic acidosis,
rhabdomyolysis
• Incontinence
• Tongue biting
• Vomiting and aspiration
• Post. shoulder dislocation
• Back pain

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Examination
• Meningeal signs
• Stigmata of substance abuse
• L.N.
• Dysmorphic features
• Skin lesions (neurocut. $, meningococcemia)
• Murmur (subacute IE)
• Complete neuro exam (focal deficit,
papilledema)

Investigations
• Glucometer
• S. Na
• Pregnancy test
• on anticonvulsant
anticonvulsant level
• Febrile
septic screen
• 1st time seizure / medically ill (DM, CA,
liver disease, meds)
basic chemistry
• ? Tox screen
• Meningeal signs
LP ± CT

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CT
• In the fully recovered patient without headache
and with fully normal mental status and
neurologic examination who has had a single,
brief seizure, a cranial CT scan can be obtained
in the emergency department or at a follow-up
visit, at the discretion of the treating physician.
• The literature on this issue for first-time
nonfebrile seizures in children is also
inconclusive.

CT
1. head trauma
2. elevated intracranial pressure
3. intracranial mass
4. persistently abnormal mental status
5. focal neurologic abnormality
6. HIV disease (or immunosuppression)
7. Hx of malignancy
8. Fever
9. Onset > 40 y/o
10. Hx of anticoagulant
11. Focal onset before generalization

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EEG
• nonconvulsive status epilepticus
• To monitor seizure activity after intubation
and neuromuscular blockade
• to help differentiate seizures from other
similar presentations
• follow-up evaluation of first-time seizures
without clear cause after a complete
emergency department evaluation.

Management
• choice to initiate anticonvulsant therapy
is dependent on:
1. the risk of seizure recurrence
2. any underlying predisposing disease
3. the risk of anticonvulsant therapy.

• It is typically not made by the

emergency physician

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Disposition
• One quarter of adult patients presenting with
seizure-related complaints has new-onset
seizures.
• Almost half of them require admission, most
because of abnormal CT scans or persistent
focal abnormalities
• appropriate guidance regarding driver's license
privileges.
• Outpatient therapy for seizure disorders should
be initiated in consultation with a neurologist, if
possible.

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