!1.04 Seizures (Convulsions, fits)
The patient may be found in the street, the hospital, or the emergency room.
The patient may complain of an "aura," feel he is "about to have a seizure,"
experience a brief petit mal "absence," exhibit the repetitive stereotypical
behavior of continuous partial seizures, the whole-body tonic stiffness or
clonic jerking of grand mal seizures, or simply be found in the gradual
recovery of the postictal phase. Patients experiencing grand mal seizures can
injure themselves, and generalized seizures prolonged for more than a couple
of minutes can lead to hypoxia, acidosis, and even brain damage.
What to do:
* If the patient is having a grand mal seizure, stand by him for a few
minutes until his thrashing subsides, to guard against injury or airway
obstruction. Usually only suctioning or turning the patient on his side is
required, but breathing will be uncoordinated until the tonic-clonic phase
* Watch the pattern of the seizure for clues to the etiology. (Did clonus
start in one place and "march" out to the rest of the body? Did the eyes
deviate one way throughout the seizure? Did the whole body participate?)
* If the seizure lasts more than two minutes, or recurs before the patient
regains consciousness, it has overwhelmed the brain's natural buffers and
may require drugs to stop. This is defined as status epilepticus, and is best
treated with diazepam (Valium) 5-l0mg iv, followed by gradual loading with
* Check a quick finger stick blood sugar (especially if the patient is
wearing a "diabetes" MedicAlert bracelet or medallion) and administer
intravenous glucose if it is below normal.
* If the patient arrives postictal, examine him thoroughly for injuries and
record a complete neurological examination (the results of which are apt to
be bizarre). Repeat the neurological exam periodically. If the patient is indeed
recovering, you may be able to obviate much of the diagnostic workup by
waiting until he is lucid enough to give a history.
* If the patient arrives awake and oriented following an alleged seizure,
corroborate the history through witnesses or the presence of injuries like
a scalp laceration or a bitten tongue. Doubt a grand mal seizure without a
prolonged postictal recovery period.
* If the patient has a previous history of seizure disorder, or is taking
anticonvulsant medications, check old records, speak to his physician, find
out whether he has been worked up for an etiology, look for reasons for
this relapse (e.g., infection, ethanol, lack of sleep), and draw blood for levels
* If the seizure is clearly related to alcohol withdrawal, ascertain why the
patient reduced his consumption. He might be broke, be suffering from
pancreatitis or gastritis that requires further evaluation and treatment,
or have decided to dry out completely. If the last, and is demonstrating signs of
delerium tremens, such as tremors, tachycardia and hallucinations, his
withdrawal should be medically supervised, and covered with benzodiazepines
(e.g. Librium, Valium, Ativan). Many emergency physicians presumptively
treat alcohol withdrawal symptoms with an intravenous infusion containing
glucose, l00mg thiamine, 2Gm magnesium and multivitamins.
* If the seizure is a new event, make arrangements for a workup, including an
EEG. About half of patients with a new onset of seizures will require
hospitalization, and most of these patients can be identified by
abnormalities on physical examination, head CT or blood counts. Other tests
(lumbar puncture, serum electrolytes, glucose, calcium) may also identify
new seizure victims who require admission.
* If the workup will be as an outpatient, the patient should be loaded with
phenytoin (Dilantin) 17-20mg/kg over 1/2 hour iv, or over 6 hours po to
protect him from further seizures. If there is any question, check a serum
phenytoin level before giving this loading dose. Patients should be on a
cardiac monitor during iv loading, which should be slowed if they develop
conduction blocks or dysrythmias.
What not to do:
* Do not stick anything in the mouth of a seizing patient. The ubiquitous
padded throat sticks may be nice for a patient to hold and bite on at the
first sign of a seizure, but do nothing to protect his airway, and are
ineffective when the jaw is clenched.
* Do not rush to give intravenous diazepam to a seizing patient. Most
seizures stop in a few minutes. It is diagnostically useful to see how the
seizure resolves on its own; also, the patient will awaken sooner if he has
not been medicated. Reserve diazepam for genuine status epilepticus.
* Be careful not to assume an alcoholic etiology. Ethanol abusers sustain
more head trauma and seizure disorders than the population at large.
* Do not treat alcohol withdrawal seizures with phenobarbital or phenytoin.
Both lack efficacy (and necessity, since the problem is self-limiting) and
can themselves produce withdrawal seizures.
* Do not rule out alcohol withdrawal seizures on the basis of a toxic serum
ethanol level. The patient may actually be withdrawing from a yet higher
* Do not be fooled by pseudoseizures. Even patients with genuine epilepsy
occasionally fake seizures for various reasons, and an exceptional
performer can be convincing. Amateurs may be roused with ammonia or
smelling salts, but few can simulate the fluctuating neurological
abnormalities of the postictal state, and probably no one can produce the
pronounced metabolic acidosis or serum lactate elevation of a grand mal
* Do not release a patient with persistent neurologic abnormalities without a
head CT or specialty consultation.
* Do not let a seizure victim drive home.
Grand mal seizures are frightening, and inspire observers to "do something,"
but usually all that is necessary is to stand by and prevent the patient from
injuring himself. The age of the patient makes some difference as to the
probable underlying etiology of a first seizure and therefore makes some
difference in disposition. Under age 3, rapid rise of temperature can cause a
generalized febrile seizure which does not lead to epilepsy, and is best
treated by control of fever. Brief febrile seizures may not require a lumbar
puncture to evaluate the cause of the fever, but these children should be
managed in consultation with the primary care physician to ensure early follow
up. In the 12 to 20-year-old patient, the seizure is probably "idio- pathic,"
although other causes are certainly possible. In the 40-year-old patient with
a first seizure, one needs to exclude neoplasm, post-traumatic epilepsy, or
withdrawal. In the 65-year-old patient with a first seizure, cerebrovascular
insufficiency must also be considered. Such a patient should be treated and
worked up with the possibility of an impending stroke, in addition to the
other possible causes. For these reasons, a patient with a first seizure who
is 30 years old or older needs to have a CT scan, preferably while in the ED.
A noncontrast study can be obtained initially. If there are abnormalities
present or if there are still suspicions of a focal abnormality, a contrast
study can be obtained at the same time or later, whichever is convenient.
Also, patients should be discharged for outpatient care, only if there is full
recovery of neurological function, with a full loading dose of phenytoin, and
with clear arrangements for follow-up or return to the ED if another seizure
occurs. An EEG can usually be done electively, except in status epilepticus. A
toxic screen may be needed to detect the many overdoses that can present as
seizures, including amphetamines, cocaine, isoniazide, lidocaine, lithium,
phencyclidine, phenytoin and tricyclic antidepressants.
* Eisner RF, Turnbull TL, Howes DS et al: Efficacy of a "standard" seizure
workup in the emergency department. Ann Emerg Med 1986;15:33-39.
* Henneman PL, DeRoos F, Lewis RJ: Determining the need for admission in
patients with new-onset seizures. Ann Emerg Med 1994;24:1108-1114.
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