Seizures

Diagnosis

First, is this a seizure or not?

• Reliable witness
• Movements described
• Incontinence
• Post ictal confusion

For tonic clonic seizures, injury patterns:

• tongue biting
• knee abrasions
• head injuries.

Status epilepticus is a medical emergency characterised by either:

• continuous seizure activity lasting for more than five minutes, or
• a series of seizures without a return to full consciousness between them.

Identifying and understanding the various type of seizures often guides clinical management. Management of seizures in the emergency department has three components.

• Terminating the seizure
• Managing the post ictal state and associated sequalae
• Preventing further seizures

Management of first seizure in adults algorithm (PDF 228.7 KB)

Seizure types

There are many different types of seizures. Seizures can be divided into three major groups:

• Focal seizures (formerly known as partial seizures)
• Generalised seizures
• Unknown seizures

Epilepsy Action Australia has more information on seizure types and seizure classification.

Seizure effects

Clinical manifestations

• Transient apnoea and subsequent hypoxia
• Catecholamine surge
• Hypertension and/or tachycardia
• Transient hyperthermia

Status epilepticus

• Hypoxaemia
• Hypercarbia
• Hypertension or hypotension
• Hyperthermia
• Depletion of cerebral glucose and oxygen
• Cardiac dysrhythmias
• Rhabdomyolysis

Pathological

• BSL - check for hypoglycaemia and treat
• Lactic acidosis which resolves quickly (within minutes to hours)
• Transient leukocytosis (hours to days)

Seizure investigations

Investigations are always driven by specific patient parameters. We have described an approach..

Lab investigations

• Glucose (BSL done immediately, if low give glucose IV)
• Full blood count (usually transiently high post ictally, returns in hours to days, may be high in sepsis or central infection)
• Urea, electrolytes and creatinine (UEC) (may indicate underlying precipitant, sodium)
• Venous blood gas (metabolic snapshot, useful particularly if ingestion suspected, think toxidromes)
• Calcium (abnormalities cause seizures)
• Urine beta-human chorionic gonadotropin (β-hCG) (if indicated)
• Venous blood gas (metabolic snapshot, useful particularly if ingestion suspected, think toxidromes)
• Liver function test (if indicated by known past history, alcohol ingestion, liver disease

Imaging, head CT (consider contrast)

For any first or partial seizure or suspicion of:

• trauma
• malignancy
• immunocompromise
• anticoagulation
• new focal neurological findings on examination.

Imaging in known seizure disorder

Head CT for:

• new focal deficits
• trauma
• persistent fever
• new character or pattern to the seizures
• suspicion of AIDS, infection
• VP shunt, previous brain tumour or surgery
• anticoagulation.

Lumbar puncture for:

• immunocompromise
• persistent fever
• severe headache (e.g. suspicion of meningitis)
• persistently altered mental status.

Other

• ECG
• EEG
• MRI

Seizure treatment

Requires immediate intervention.

Ensure:

• ABCDE
• Escalate via CERS
• Control the situation - physically, chemically
• Patient position, prevent harm (patient and staff)
• Suction
• Oxygen
• Terminate the seizure chemically
• Maintain in as close to recovery position as possible
• Protect the head and limbs from injury
• Get IV access