Seizures - Introduction
No me gusta!
The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.
An overview of seizures and review of seizure terminology.
C3 - Seizures in Adults
Jessica Mason MD, Stuart Swadron MD, Mel Herbert MD
* Drug doses are a guide only, always check second source and follow local practice guidelines
Take Home Points
- Most seizures stop spontaneously - but those patients seizing for more than 5 minutes are unlikely to stop.
- The initial priority when a patient is actively seizing is to protect them from physical harm and stop the seizure.
- Benzodiazepines, through any route available, are first line in treatment, followed by a repeat dose and then a stepwise progression to second and third line drugs with endotracheal intubation as necessary.
- Unless the seizure is typical in a patient with known seizure disorder, serious diagnoses, such as poisoning, brain tumor, and meningitis, must be considered and worked-up as appropriate.
- In many cases, diagnoses other than seizure must be entertained - notably a cardiac event such as syncope.
- New onset seizures in patients who are pregnant and with HIV/AIDS may represent a variety of challenging and serious diagnoses - early consultation is advised.
Seizures frighten everybody. They can be distressing not only for patients but also for their families, public bystanders and even emergency providers. Because the convulsions associated with seizures can be so dramatic, we tend to lose our ability to think in a logical manner when a patient is actively seizing. In this episode of C3, we cover the initial approach to the seizing patient, how to manage status epilepticus and how to disposition these patients from the emergency department.
- Some important definitions:
- Seizure - abnormal neurologic function caused by inappropriate electrical discharges in the brain
- Convulsion - motor activity from seizure
- Epilepsy - condition of recurrent seizures, not due to a specific structural (e.g. brain tumor) or metabolic (e.g. hypoglycemia) cause
- Key Types of Seizures:
- This is what most people think of when they think of seizure
- Alternating stiffening (tonic) and rhythmic jerking (clonic)
- 3 typical phases:
- Tonic - abrupt onset of LOC, rigidity, with apnea and cyanosis, usually urinate and sometimes vomit
- Clonic - symmetric, rhythmic jerking
- Post-ictal - somnolence, fatigue, may last hours
- Classically in school-aged children
- Usually resolve as the child grows up
- Can have up to 100 per day
- Brief (seconds sometimes), LOC but no loss of postural tone
- Patients appear confused, detached, withdrawn
- Stops abruptly with no post-ictal phase
- Simple partial/focal seizures do not involve LOC
- Complex partial seizures are the fascinating ones
- They can appear to cause personality changes, hallucinations
- Generally present differently than the typical “seizure” patient, more likely altered mental status
Claassen J et al. Emergency Neurological Life Support: Status Epilepticus. Neurocrit Care (2015) 23:S136–S142. https://www.ncbi.nlm.nih.gov/pubmed/26438462
Falco-Walter JJ, Bleck T. Treatment of Established Status Epilepticus. J Clin Med. 2016 May; 5(5): 49. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882478/
Huff S et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures. From the American College of Emergency Physicians Clinical Policies Subcommittee. Ann Emerg Med. 2014;63:437-447. http://www.annemergmed.com/article/S0196-0644(14)00080-8/fulltext
Khoujah D, Abraham MK. Status Epilepticus: What’s New? Emerg Med Clin N Am 34 (2016) 759–776. https://www.ncbi.nlm.nih.gov/pubmed/27741987
Krumholz A, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015 Oct 27;85(17):1526-7. https://www.ncbi.nlm.nih.gov/pubmed/26503589
Webb J, et al. An Emergency Medicine-Focused Review of Seizure Mimics. J Emerg Med 2017; 52 (5):645-653.