inpatient / Neurology
Seizure
# 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
Assessment:
-- 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 ***.
Plan:
Workup
-- 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
Treatment
-- 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)
PDF coming soon!
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
- Altered Mental Status Rapid Response
- The Curbsiders Podcast - #257 Seizure Basics for Primary Care
