1. Soma Pathak, MD PGY-2 Emergency Medicine
Seizures
Soma Pathak, MD
PGY-2
Emergency Medicine

2. Overview Definition Epidemiology Clinical Features
Differential Diagnosis
Treatment
Cases

3. Definitions
Seizure: episode of abnormal neurologic function caused by inappropriate electrical discharge of brain neurons.
Epilepsy: clinical condition in which an individual is subject to recurrent seizures.

4. Epidemiology
100,000 new cases of seizures diagnosed in the US each year
Incidence of seizures world-wide is 30.9 to 56.8 per 100,000.
Highest rates among those less than 20 years old followed by those over 60.
Male>Female

5. Generalized Seizures
Caused by a nearly simultaneous activation of the entire cerebral cortex

6. Partial seizures
Due to electrical discharges in a localized structural lesion of the brain.
Affects whatever physical or mental activity that area controls.

7. Partial (focal) seizures
Simple partial no alteration of consciousness
Complex partial consciousness impaired
Partial seizures (simple or complex) with secondary generalization

8. Classification of Seizures
Generalized seizures (consciousness always lost)
Tonic clonic seizures (grand mal)
Absence seizures (petit mal)
Myclonic seizure
Clonic seizures
Atonic seizures

9. Causes: secondary seizures
Trauma (recent or remote)
Intracranial hemorrhage
Eclampsia
Hypertensive encephalopathy
Structural abnormalities
Vascular lesion (aneurysm, AV malformation)
Mass lesion
Degenerative disease
Congenital abnormalities

10. Causes: secondary seizures
Toxins and drugs
Anoxic brain injury
Metabolic disturbances
Hypo or hyperglycemia
Hypo or hypernatremia
Hyperosmolar states
Uremia
Hepatic failure
Hypocalcemia, hypomagnesemia (rare)

11. Features: generalized seizures
Abrupt loss of consciousness and loss of postural tone
May then become rigid
With extension of the trunk and extremities
Apnea
Cyanosis
Urinary incontinence

12. Features: tonic clonic seizures
As the tonic (rigid) phase subsides, clonic (symmetric rhythmic) jerking of the trunk and extremities develop
Episode lasts from seconds
Consciousness returns gradually
Postictal confusion may persist for several hours

13. Features : absence seizures
Brief, usually lasting only a few seconds.
Loss of consciousness without losing postural tone.
Appear confused or withdrawn, and current activity ceases.
May stare and have twitching of their eyelids.
Do not respond to voice or other stimulation
Are not incontinent.
End abruptly, and there is no postictal period.

14. Clinical features of simple partial
Remain localized and consciousness is not affected.
Unilateral tonic or clonic movements limited to one extremity suggest a focus in the motor cortex, while tonic deviation of the head and eyes suggest a front lobe focus.
Visual symptoms often result from an occipital focus, while olfactory or gustatory hallucinations may arise from the medial temporal lobe
Sensory phenomena, or aura are often the initial symptoms of attacks.

15. Status epilepticus
Continuous seizure activity lasting for at least 30 min
Two or more seizures without intervening return to baseline
Non-convulsive status epilepticus is associated with minimal or imperceptible convulsive activity and is confirmed by EEG

16. History Careful history Important historical information:
Include rapidity of onset,
Presence of a preceding aura
Progression of motor activity (local or generalized)
Incontinence.

17. History
Duration of the episode and whether there was postictal confusion
Contributing factors:
Sleep deprivation
Alcohol withdrawal
Infection
Use or cessation of other drugs

18. History: first time seizures
History of head trauma
Headache
Pregnancy or recent delivery
History of metabolic derangements or hypoxia
Systemic ingestion or withdrawal and alcohol use.

19. Physical Exam: Injuries resulting from the seizure
such as fractures, sprains, strains, posterior shoulder dislocation, tongue lacerations, and aspiration.
Localized neurological deficits
Todd’s paralysis

20. Differential diagnosis
Syncope
Hyperventilation syndrome
Complex migraine
Movement disorders
Narcolepsy
Pseudo-seizures

21. Treatment: Airway: Oxygen Pulse oximetry Endotracheal intubation
for prolonged seizure
If RSI is performed, a short acting paralytic agent should be used so that ongoing seizure activity can be observed

22. Treatment: Breathing: Circulation: IV access
Suction
Airway adjuncts
Circulation: IV access
IV glucose if confirmed hypoglycemia

23. First Line Medication: Benzodiazepines
Midazolam (Versed) IV/IM
Diazepam (Valium) IV/ET/IO/PR
Lorazepam (Ativan) IV/IM

24. Second line medications:
Phenytoin/fosphenytoin
Phenobarbital

25. Third line medication:
General anesthesia with continuous EEG
Infusions of midazolam, propofol, or pentobarbital
Inhaled isoflurane

26. First Line Anticonvulsants
DRUG
ADULT DOSE
PEDS DOSE
OTHER INFO
Diazepam
.2mg/kg up to 20mg at 2mg/min
.2-.5mg/kg IV/IO or mg/kg PR up to 20mg
CNS/CV/Resp depression
Onset 1min
Lasts 20-30min (longer PR)
Lorazepam
.1mg/kg IV max 10mg at 2mg/min
**Intranasal use promising
.05-.1mg/kg IV
Onset 2min
Lasts >12hrs
Midazolam
.1mg/kg IV up to 10mg at 1mg/min or .2mg/kg IM
.15mg/kg IV
.2mg/kg IM
Less depression
Short duration

27. Case 1:
14 month old healthy female with cough and nasal congestion x 2 days, with tactile temperature and 30 second episode of “shaking”?
PE?
Dx?
Treatment?

28. Seizures in children Aged 0-9 years, prevalance is 4.4 cases per 1000,
Aged10-19 years old 6.6 cases per 1000
Simple febrile convulsions occur in 3-4% of children

29. Febrile seizures Antiepileptic drug therapy are only used in pts with:
Underlying neuro deficit (ie CP)
Complex febrile seizure
Repeated seizure in the same febrile illness
Onset under 6 mos of age or more than 3 febrile seizures in 6 mos.

30. Febrile seizures: Aged 3 month to 5 years Identify and treat cause
Acetaminophen, ibuprofen and tepid water baths.
Family history increases risk.

31. Case 2
19 year old healthy female breast feeding a newborn has a tonic-clonic seizure
PE?
Dx?
treatment?

32. Eclampsia
Pregnant women beyond 20 weeks’ gestation or up to 8 weeks postpartum.
Seizures
Hypertension
Edema
Proteinuria

33. Eclampsia: Treatment: administration of magnesium sulfate 4 g IV
Followed by 1-2 mg/ hr, in addition to antiepileptic meds

34. Case 3:
50 year old male with tonic-clonic seizure lasting 2 minutes. Pt is on tegretol.
PE?
Dx?
Treatment?

35. Epilepsy Breakthrough seizures vs. noncompliance with medications
Precipitating factors
Infection
Drug use
Treat or stabilize any injuries secondary to convulsions

36. Epilepsy: management ABC’s Monitor VS and check blood glucose
Treat any injuries
Transport to appropriate hospital
IV and ALS monitor

37. A/P: no longer seizing:
Recovery position IV
Blood glucose
Medication history

38. A/P is seizing still Airway assessment (npa, suction, ETT prn)
Protect patient from self injury
Pulse-ox, monitor, IV access, blood glucose
Hypoglycemia is the most common metabolic but can also be a result of prolonged seizure
Medications

39. Case 4: 34 yo male with hx of alcoholism found s/p seizure.
Pt is confused and combative.
Vomiting.

40. Delerium Tremens (DT’s)
Advanced stage of alcohol withdrawal
Altered mental status
Generalized seizures
6-48 hours after the last drink.
Status epilepticus

41. Delerium Tremens (DT’s)
Tremors
Irritability
Insomnia
Nausea/vomiting
Hallucinations (auditory, visual, or olfactory)
Confusion
Delusions
Severe agitation

42. Treatment: Airway IV access
Suction at hand
high risk for aspiration
oxygen
IV access
Immediate glucose testing or D50 administration
thiamine administration (100 mg IV)
benzodiazepines in actively seizing pts.

43. Treatment of DT’s: Do not use neuroleptics
Administer adequate sedation
To blunt agitation to and prevent the exacerbation of hyperthermia, acidosis, and rhabdomyolysis.

44. Delirium tremens: Potentially fatal form of ethanol withdrawal.
Symptoms may begin a few hours after the cessation of ethanol, but may not peak until hours.
Early recognition and therapy are necessary to prevent significant morbidity and death.

45. Case 5:
22 yo female with 2 episodes of “shaking” in last 6 hours with active seizing for 15 minutes.
PE?
Dx?
Treatment?

46. Status Epilepticus
Continuous seizure activity lasting for at least 30 min, or two or more seizures without intervening return to baseline
Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min)
Impending SE if >3 tonic-clonic seizures within 24hrs
Generalized or Partial

47. Status Epilepticus The longer the seizure continues
The more difficult it is to stop
The more likely permanent CNS injury will occur

48. Treatment
Protect airway airway (NPA, OPA, ETT). If RSI is required, use short acting paralytics.
Obtain IV access
FS blood glucose
Cardiac monitoring

49. Lastly induction of general anesthesia w. cont. EEG
First line
Diazepam (Valium) IV/ET/IO/PR
Lorazepam (Ativan) IV/IM
Midazolam (Versed) IV/IM
Second line
Phenytoin/fosphenytoin
Phenobarbital (may cause respiratory and circulatory depression)
Lastly induction of general anesthesia w. cont. EEG
Infusions of midazolam, propofol, or pentobarbital
Inhaled isoflurane

50. Questions??