I have always been able to sort out seizure vs pseudoseizure in an actively convulsive patient by cracking 2 ammonia caps and holding them to the patient's nostrils. It always works to break the convulsion in pseudoseizure, and, unless I am also inadvertently performing some form of olfactory countershock cerebroversion in true seizure patients, it is 100% accurate in sorting out the DDx. Quick, cheap, simple. Also noteworthy that it effectively prevents recurrent or serial pseudoseizure for the remainder of the ED visit.
I like the ammonia trick. I did once as a resident and got yelled at by a senior faculty member saying it was somewhat "cruel and unusual" to do to someone when you know it's not a "real" seizure. But I do think it helps sort things out. Those ammonia snaps are really hard to tolerate under your nose! Ever tried it? There's your homework....
One pearl to help with the breaking of the news that "this is a pseudo seizure" is to ask the patient if they have ever been molested. The association between the two is nearly 100% and when they answer yes they think you have ESP and can further buy in to the diagnosis. Obviously this is something that should be done in the setting that would make the pt feel comfortable answering i.e. not with their new boyfriend sitting there. Later when the patient has been clued in, it makes the subsequent referral to psych all the easier.
Mel, Great lecture and who doesn't love James Brown? While ammonia caps work, I agree they can be seen as cruel. My trick is to stand off to the side of the bed where the patient cant see me and drop an old style metal bed pan on the floor. The loud clang almost always stops the seizure.
I had a question for the presenters of this section: i had a patient recently with multiple events of what was very clearly pseudo seizures (psych/personality issues, -ve MRI and EEG, speaking/responding during the seizure events), who also had an elevated lactate (no other source other than seizure activity was found for her elevated lactate, and it normalized on repeat testing during her ED stay). The internist and I were discussing whether or not an elevated lactate would make it more likely that this was an actual seizure, and was wondering if the presenters had any thoughts on this. My feeling is that, regardless of whether or not the generalized tonic-clonic or seizure-like activity is generated from an epileptogenic focus, the increased muscle activity would produce excess lactate, so it doesn't make it more likely that this is a genuine seizure as opposed to a pseudoseizure.
BIg T - March 6, 2013 9:37 AM
so much fun to listen to
Aaron B. - March 6, 2013 9:39 AM
Thanks Shlomo, it was fun making it. Dr. Stellpflug was great... We'll try to pick up more from him in the future.
Patrick S., M.D. - March 7, 2013 9:46 AM
I have always been able to sort out seizure vs pseudoseizure in an actively convulsive patient by cracking 2 ammonia caps and holding them to the patient's nostrils. It always works to break the convulsion in pseudoseizure, and, unless I am also inadvertently performing some form of olfactory countershock cerebroversion in true seizure patients, it is 100% accurate in sorting out the DDx. Quick, cheap, simple. Also noteworthy that it effectively prevents recurrent or serial pseudoseizure for the remainder of the ED visit.
piyush m., dr - March 7, 2013 10:58 PM
That's what I have seen - one senior ED guys doing to most of young hyperventilating seizure pts !
Jan S. - March 12, 2013 12:13 PM
I like the ammonia trick. I did once as a resident and got yelled at by a senior faculty member saying it was somewhat "cruel and unusual" to do to someone when you know it's not a "real" seizure. But I do think it helps sort things out. Those ammonia snaps are really hard to tolerate under your nose! Ever tried it? There's your homework....
brendan c. - March 12, 2013 3:41 PM
One pearl to help with the breaking of the news that "this is a pseudo seizure" is to ask the patient if they have ever been molested. The association between the two is nearly 100% and when they answer yes
they think you have ESP and can further buy in to the diagnosis.
Obviously this is something that should be done in the setting that would make the pt feel comfortable answering i.e. not with their new boyfriend sitting there. Later when the patient has been clued in, it makes the subsequent referral to psych all the easier.
Michael M. - March 13, 2013 4:57 AM
Mel, Great lecture and who doesn't love James Brown? While ammonia caps work, I agree they can be seen as cruel. My trick is to stand off to the side of the bed where the patient cant see me and drop an old style metal bed pan on the floor. The loud clang almost always stops the seizure.
Patrick J Hawley, MD - March 14, 2013 8:01 AM
A very nice review with engaging presentation; the format and style were great. Keep up the good work. (James Brown is the bomb)
Scott V. - November 22, 2013 1:50 PM
I hard sternal rub also does the trick nicely as well. quick and easy:)
L S, MD - December 3, 2013 1:10 PM
I had a question for the presenters of this section: i had a patient recently with multiple events of what was very clearly pseudo seizures (psych/personality issues, -ve MRI and EEG, speaking/responding during the seizure events), who also had an elevated lactate (no other source other than seizure activity was found for her elevated lactate, and it normalized on repeat testing during her ED stay). The internist and I were discussing whether or not an elevated lactate would make it more likely that this was an actual seizure, and was wondering if the presenters had any thoughts on this. My feeling is that, regardless of whether or not the generalized tonic-clonic or seizure-like activity is generated from an epileptogenic focus, the increased muscle activity would produce excess lactate, so it doesn't make it more likely that this is a genuine seizure as opposed to a pseudoseizure.
Mohammed A. - November 26, 2014 12:04 PM
i always consult pysch on these pts but they never have much input. wondering if anyone knows any therapy for these people ie ssri?