inpatient / Neurology


Last Updated: 1/8/2023

# Seizure

Acute Managment: lie patient on their side, do not try to restrain patient, make sure protecting airway, time and video record the seizure if able; ativan 1-2mg IV if does not break on its own within a few minutes, involve neurology consultants

-- History: *** previous seizure, prodrome (palpitations, sweating, N/V), meds and adherence, triggers (exertion, fatigue, stress, urination/defecation), tongue biting, incontinence, lateralizing signs, alcohol use
-- Clinical/Exam: *** CN abnormalities, facial droop, hemiparesis, dysphagia, dizziness, ataxia
-- Data: *** glucose, UDS, AED levels, CBC, BMP, VBG, CK, INR, lactate
-- Etiology/DDx: *** Seizure (primary epilepsy, stroke, hemorrhage, withdrawal, masses, trauma, hypoglycemia, hypoxia, meds, infection, fevers, eclampsia, PRES); syncope, TIA, migraine, PNES, myoclonus, dystonia, tremor

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- EEG within 24-48 hours if not seizing
-- Continuous telemetry
-- MRI with contrast for first seizure, focal neuro exam, h/o trauma, malignancy, HIV 
-- LP and BCx if fevers and immunocompromised or no other etiology identified

-- Ativan 1-2mg IV x2, then call neurology to discuss AED load (Keppra 40-60mg/kg, max 4.5g) 
-- If status epilepticus (>5 mins or 2+ seizures with incomplete recovery between them in 24 hrs) – Ativan 4mg q5min 2-3 times, then call neurology to discuss AED load and intubate to protect airway; if no IV, diazepam rectal or midazolam IM
-- No driving until event-free for 6 months (state dependent)

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If You Remember Nothing Else

When first diagnosed, seizures are often indicative of another underyling neurological process and you should get an MRI. Patients with a known history of seizure will commonly present due to issues with medication adherence. Push Ativan 1-2mg to break a seizure and discuss an AED load with neurology consultants (often Keppra). Intubate patients who are not protecting their airway.

Clinical Pearls

  • Seizures are short-lived events caused by abnormal electrical discharges in the brain leading to a variety of symptoms including alteration in conciousness and motor and sensory disturbances
  • The most common type of seizure is tonic-clonic, also known as grand-mal seizure
  • Most seizures resolve in a couple minutes without intervention
  • Its very helpful to try and film the seizure activity for later review with neurology consultants
  • Common triggers include sleep deprivation, alcohol and other drug use, and stress
  • New diagnosis of seizure should undergo a thorough neurological workup, including MRI 

Trials and Literature

  • Initial Management of Seizure in Adults - Review (NEJM, 2021)
  • New-Onset Seizure in Adults and Adolescents - Review (JAMA, 2016)

Other Resources