DESCRIPTION 
- Generalized seizures:
- Classically tonic–clonic (grand mal)
- Begin as myoclonic jerks followed by loss of consciousness
- Sustained generalized skeletal muscle contractions
- Nonconvulsive generalized seizures:
- Absence seizures (petit mal); alteration in mental status without significant convulsions or motor activity
- Partial seizures:
- Simple:
- Brief sensory or motor symptoms without loss of consciousness (i.e., Jacksonian)
- Complex:
- Mental and psychological symptoms
- Affect changes
- Confusion
- Automatisms
- Hallucinations
- Associated with impaired consciousness
- Status epilepticus:
- Variable definitions:
- Seizure lasting longer than 5–10 min
- Recurrent seizures without return to baseline mental status between events
- Life-threatening emergency with mortality rate of 10–12%
- Highest incidence in those < 1 yr and > 60 yr of age
- At least one-half of patients presenting to the ED in status do not have a history of seizures.
- Alcohol withdrawal seizures ("rum fits"):
- Peak within 24 hr of last drink
- Rarely progress to status epilepticus
- Patients with a single seizure have a 35% risk of recurrent seizure within 5 yr
Pediatric Considerations
Febrile seizures are generalized seizures occurring between 3 mo and 5 yr of age:
- Typically lasts < 15 min
- Associated with a rapid rise in temperature
- Without evidence of CNS infection or other definitive cause
ETIOLOGY
[Outline]
SIGNS AND SYMPTOMS
- Altered level of consciousness
- Involuntary repetitive muscle movements:
- Tonic posturing or clonic jerking
- Seizures of abrupt onset:
- Aura may precede a focal seizure
- Duration usually 90–120 sec:
- Impaired memory of the event
- Postictal state is a brief period of confusion and somnolence following a seizure
- Evidence of recent seizure activity:
- Other findings may suggest etiology of seizure:
- Fever and nuchal rigidity (CNS infection)
- Needle tracks; stigmata of liver disease (drugs and alcohol)
- Head trauma:
- Papilledema (increased intracranial pressure)
- Lateralized weakness, sensory loss, or asymmetric reflexes
History
- History of seizures:
- Recent illness
- Head trauma
- Headaches
- Anticoagulation therapy
- Fever
- Neck stiffness
Physical Exam
- Complete neurologic exam:
- Complete secondary and tertiary survey to evaluate for any trauma secondary to seizure or potential cause for seizure
ESSENTIAL WORKUP
- A thorough history is the most valuable part of the workup:
- Witness accounts
- History of prior seizures
- Presence of acute illness
- Past medical problems
- History of substance use
- Patients with chronic seizure disorder and typical seizure pattern may need to have only serum glucose and anticonvulsant levels checked
- New-onset seizure mandates workup:
- Electrolytes including calcium, phosphorus
- Head CT
- Toxicology screen
- Pregnancy test if woman is of childbearing age
- Lumbar puncture indicated if:
- New-onset seizure with fever
- Severe headache
- Immunocompromised state
- Persistently altered mental state:
- Search for specific underlying cause
- Patient's condition and resources for follow-up determine whether all these tests must be done in the ED
Pediatric Considerations
- A child with a 1st febrile seizure should receive fever workup as dictated by clinical condition
- Inquire about family history of febrile seizures
- Labs and radiographs as needed to determine source of fever
- Lumbar puncture for 1st febrile seizure:
- Consider if age < 1 yr
- Ill appearing
- Lethargy or poor feeding
- Exam difficult
- Unreliable follow-up
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Serum anticonvulsant levels
- Blood–alcohol level
- Toxicology screen
- CBC:
- Chemistry panel:
- Lactate may be elevated
- CSF:
- May have transient increase in WBC to 20/µL
Imaging
- Noncontrast head CT:
- Persistent or progressive alteration of mental status
- Focal neurologic deficits
- Seizure associated with trauma
- CT scan with contrast should be obtained in HIV-positive patients to rule out toxoplasmosis
- MRI is sensitive for low-grade tumors, small vascular lesions, early inflammation, and early cerebral infarcts:
- Consider electively in new-onset seizures
Diagnostic Procedures/Surgery
- EEG may be arranged with neurology on an outpatient basis
- Bedside EEG may be performed in ED if there is suspicion of nonconvulsive status epilepticus or psychogenic seizures
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Anticonvulsant as per local protocol
INITIAL STABILIZATION/THERAPY
- Airway management as indicated
- Pulse oximetry, oxygen with suction available:
- C-spine precautions
- Rapid-sequence intubation if patient cannot protect airway or with hypoxia or major head trauma
- IV access, rapid determination of serum glucose:
- Lorazepam or diazepam for active seizures
- Naloxone if concern for narcotic overdose
ED TREATMENT/PROCEDURES
- 1st-time seizure:
- Normal head CT if performed
- Return to baseline with normal neuro exam:
- Discharge with close follow-up with PCP and/or neurologist
- 1st-time seizure:
- Structural lesion on CT or MRI:
- Start antiepileptic drug (AED) in consultation with PCP and/or neurologist
- Recurrent seizure not on AED:
- Start AED in consultation with PCP and/or neurologist
- Recurrent seizure with subtherapeutic AED level:
- IV and/or PO load current AED
- Recurrent seizure with therapeutic AED level:
- Need careful evaluation for cause of seizures, new lesions, etc.:
- Adjust and/or add AED in consultation with neurologist
- Seizure in a pregnant patient:
- Evaluate as other seizure patients
- Strongly consider eclampsia if > 20-wk gestation
- OB consultation, arrange for C-section
- Magnesium
- Seizures related to alcohol:
- Determine if seizure is caused by withdrawal (typically 6–48 hr after cessation of drinking) or another cause
- Management of withdrawal seizures is benzodiazepines
Pediatric Considerations
- Fever control with acetaminophen and ibuprofen
- Anticonvulsants not needed for febrile seizures
- Anticonvulsants should be prescribed in conjunction with neurologist.
MEDICATION
- Acetaminophen: 500 mg PO/PR q4–6h; do not exceed 4 g/24 h
- Diazepam: 0.2 mg/kg IV per dose; 0.5 mg/kg PR
- Fosphenytoin: 15–20 mg/kg phenytoin equivalents (PE) at rate of 100–150 mg/min IV/IM
- Ibuprofen: 5–10 mg/kg PO
- Levetiracetam: Start 500 mg PO/IV q12h (peds: Start 20 mg/kg/d PO div. BID; age 4–15 yr)
- Lorazepam: 2–4 mg IV/IM (peds: 0.05–0.1 mg/kg IV per dose)
- Naloxone: 0.4–2 mg IV/IM/SQ (peds: 0.1 mg/kg IV/IM/SQ)
- Phenobarbital: 15–20 mg/kg IV at rate of 1 mg/kg/min (plan to protect airway)
- Phenytoin: 15–20 mg/kg IV at rate of 40–50 mg/min (peds: Use rate of 0.5–1 mg/kg/min)
- Propofol: 5–50 µg/kg/min IV, titrate to effect (plan to protect airway)
- Valproate sodium: 10–20 mg/kg/d
First Line
Benzodiazepines
Second Line
- Fosphenytoin
- Levetiracetam
- Phenobarbital
- Phenytoin
- Propofol
- Valproate sodium:
- works as well as second line agent in status epilepticus and can be given faster
[Outline]
DISPOSITION
Admission Criteria
- Patients with status epilepticus should be admitted to the ICU
- Patients with seizures secondary to underlying disease (e.g., meningitis, intracranial lesion) must be admitted for appropriate treatment and monitoring
- Patients with poorly controlled repetitive seizures should be admitted for monitoring
- Delirium tremens
Discharge Criteria
- Patient with normal workup and appropriate neurology follow-up
- Uncomplicated seizure in patient with chronic seizure disorder
- Seizure secondary to reversible cause:
- Hypoglycemia if blood sugar has stabilized
- Alcohol withdrawal if baseline mental status and no further seizures
- Simple febrile seizure
Issues for Referral
- Consider early neurology follow-up
- Anticonvulsant drug level monitoring
FOLLOW-UP RECOMMENDATIONS
No driving until seizures are under control
[Outline]
- ACEP Clinical Policies Subcommittee (Writing Committee) on Seizures; Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63:437–447.
- French JA, Pedley TA. Clinical practice. Initial management of epilepsy. N Engl J Med. 2008;359:166–176.
- Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure. Emerg Med Clin North Am. 2011;29:41–49.
- Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007;69:1996–2007.
See Also (Topic, Algorithm, Electronic Media Element)