Abstract
Seizures are defined as transient occurrences of signs or symptoms related to abnormal excessive or synchronous neuronal activity in the brain. Acute seizures comprise approximately 1% of all emergency department visits. Acutely, most seizures are identified by motor symptoms, such as clonic jerking. The most common seizure emergencies are acute repetitive seizures, an abrupt increase in seizure frequency compared to baseline, and status epilepticus (SE), at least 30 min of continuous seizure activity or multiple seizures without return to neurological baseline. Convulsive seizures are easily recognized however nonconvulsive seizures are less clear yet are present in nearly 20% of patients with altered mental status (AMS) who receive electroencephalography (EEG). A period of AMS occurring in the period following a seizure is referred to as a postictal state.
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Introduction
Seizures are defined as transient occurrences of signs or symptoms related to abnormal excessive or synchronous neuronal activity in the brain. Acute seizures comprise approximately 1% of all emergency department visits. Acutely, most seizures are identified by motor symptoms, such as clonic jerking. The most common seizure emergencies are acute repetitive seizures, an abrupt increase in seizure frequency compared to baseline, and status epilepticus (SE), at least 30 min of continuous seizure activity or multiple seizures without return to neurological baseline. Convulsive seizures are easily recognized; however nonconvulsive seizures are less clear yet are present in nearly 20% of patients with altered mental status (AMS) who receive electroencephalography (EEG). A period of AMS occurring in the period following a seizure is referred to as a postictal state.
Signs/Symptoms
Seizures have a wide variety of possible manifestations, however common signs and symptoms include:
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Mental status changes (confusion, amnesia, catatonia, psychosis, delirium, agitation, etc.)
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Altered sensation (visual, gustatory, olfactory, etc.)
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Convulsive motor activity (tonic contractures, clonic jerking)
Life-threatening Symptoms/Signs
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Hyperthermia
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Hypertension (though progresses to hypotension as status epilepticus progresses)
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Cardiac arrhythmias
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Rhabdomyolysis
Differential
Most seizures are unprovoked or occur from progression of symptomatic causes; however in hospitalized patients the vast majority of seizures or SE have an acute symptomatic cause. Potential causes include:
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traumatic brain injury
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stroke
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hemorrhage
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CNS infections or tumors
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metabolic abnormalities (for example, hyponatremia)
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alcohol withdrawal
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Illicit substances and medications can also lower the seizure threshold
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*Epileptic seizures should also be differentiated from psychogenic nonepileptic seizures
Testing
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Laboratory studies should be directed but could include:
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Basic metabolic panel, calcium, magnesium, phosphate to rule out metabolic causes
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CBC
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Liver function tests
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Troponin
Antiepileptic drug (AED) levels, particularly if patient is known to be prescribed an AED such as phenytoin or valproic acid
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HCG level for women of reproductive age
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Other studies:
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EEG
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Imaging (must balance the value of imaging with the cost of delaying treatment)
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Lumbar puncture & cerebrospinal fluid analysis if safe to do so and there is suspicion for encephalitis or subarachnoid hemorrhage
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Treatment
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Airway management and respiratory support as indicated
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Place patient in left-lateral decubitus position
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Remove any foreign objects from mouth
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Cardiac monitoring
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Correct fluid and electrolyte imbalances
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If hypoglycemic (<80 mg/dL) administer 100 mg of thiamine followed by 20–50 g of dextrose 50% solution
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First line treatment for managing SE: benzodiazepines
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Lorazepam—0.1 mg/kg at a rate of 2 mg/min
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Midazolam—0.2 mg/kg, initial dose of 10 mg IM
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Diazepam—0.2 mg/kg at a rate of 5 mg/min
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Second line treatment: AEDs
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Phenytoin—20 mg/kg IV loading dose at a rate 50 mg/min; 100 mg every 6–8 h maintenance dose
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Valproate—20–40 mg/kg loading dose; 4–6 mg/kg every 6 h maintenance
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Levetiracetam—2000–4000 mg loading dose; 10–15 mg/kg every 12 h maintenance
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Lacosamide—200–400 mg loading dose; 200–300 mg every 12 h maintenance
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Third line interventions for SE include propofol, pentobarbital, and ketamine
Tool
Potential Causes of Provoked Seizures
Drugs of Abuse | Alcohol |
Stimulants | |
Ecstasy | |
Phencyclidine (PCP) | |
Lysergic acid diethylamide (LSD) | |
Infection/Inflammation | Meningitis |
Encephalitis | |
Cerebritis | |
Lesions | Tumors |
Stroke | |
Hemorrhage | |
Systemic | Eclampsia |
Thyrotoxicosis | |
Extreme fever | |
Metabolic Disorders | Hypoglycemia, Hyperglycemia |
Hyponatremia, Hypernatremia | |
Hypocalcemia | |
Hypomagnesemia | |
Antibiotics | Penicillins |
Isoniazid | |
Rifampin | |
Antimalarials | |
Metronidazole | |
Antiarrhythmic agents | Digoxin |
Lidocaine | |
Antidepressants | Bupropion |
Cyclics | |
Antipsychotics | Clozapine |
Haloperidol | |
Pain Medications | Tramadol |
Demerol | |
Fentanyl | |
Miscellaneous Medications | Baclofen |
Phenytoin (at supratherapeutic levels) | |
Calcineurin inhibitors (cyclosporine, tacrolimus) | |
Lithium | |
Chemotherapeutic agents | |
Multiple sclerosis medications | |
Withdrawal from | Opiates |
Alcohol | |
AEDs (especially benzodiazepines and barbituates) | |
Trauma |
References
Fisher RS, Boas WVE, Blume W, Elger C, Genton P, Lee P, Engel J. Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). Epilepsia. 2005;46(4):470–2.
Slattery DE, Pollack CV. Seizures as a cause of altered mental status. Emerg Med Clin North Am. 2010;28(3):517–34.
Foreman B, Hirsch LJ. Epilepsy emergencies: diagnosis and management. Neurol Clin. 2012;30(1):11–41.
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Sharp, C.S., Wilson, M.P. (2018). Seizures. In: Nordstrom, K., Wilson, M. (eds) Quick Guide to Psychiatric Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-319-58260-3_25
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DOI: https://doi.org/10.1007/978-3-319-58260-3_25
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