Loss of Consciousness in a Patient With Seizure Disorder

Case Study

A rapid response event was initiated by the bedside nurse for a patient because of seizure-like activity. A phlebotomist was preparing to draw labs from the patient when she began to shake uncontrollably and lost consciousness. The phlebotomist promptly alerted the patient’s nurse. The nurse checked on the patient, and the rapid response was called. Per the bedside nurse, the patient was a 42-year-old female with a history of anxiety, depression, fibromyalgia, GERD, and seizure disorder on levetiracetam; she was admitted for lower extremity chemical burns that she had sustained at her job.

Vital Signs

Temperature: 98.4 °F, axillary
Blood Pressure: 126/72 mmHg
Heart Rate: 87 beats per min (bpm) – normal sinus rhythm on telemetry
Respiratory Rate: 16 breaths per min
Pulse Oximetry: 98% on room air

Focused Physical Examination

A quick exam revealed a young woman lying in bed slumped to the side. The patient would not open her eyes on command and resisted passive eye-opening by the rapid response resident. There were no frothy or bloody secretions around her mouth. There was no tongue laceration or other oral trauma noted. Her heart sounds demonstrated a regular rate and rhythm without any murmurs. Her distal pulses were intact. Her bilateral lower extremities were wrapped in bandages. Auscultation of the lungs did not reveal any abnormalities. Her abdomen was soft and non-tender. After the abdominal exam, the patient began to have twitching of her legs, arms, and side to side movement of her head. She would not answer questions. Her hand was lifted above her face and dropped to avoid hitting her face. A sternal rub made the jerking movements stop; the patient opened her eyes immediately and started answering questions appropriately. No postictal confusion was noticed. Her cranial nerve testing did not demonstrate any abnormalities. Her oxygen saturation did not drop during this event.

Interventions

Given the presentation of seizure-like activity in the setting of a known seizure disorder, there was initially a significant concern for an epileptic seizure. A bedside glucose level was checked and found to be 99 mg/dL. A complete blood count (CBC) and a basal metabolic panel were drawn to evaluate for possible infectious or metabolic abnormalities causing her symptoms. Lactate and prolactin levels were also drawn to assess for signs that the patient may have had an epileptic seizure. Additional head imaging was not ordered as the patient quickly returned to her baseline, with no postictal focal neurological deficits and stable vital signs during her witnessed episode. A routine electroencephalogram (EEG) was ordered for further evaluation. Lab test results were available shortly after the rapid response, and all were within normal limits. Given the strong suspicion of non-convulsive seizures, a neuro-psychiatry consult was placed for further evaluation.

Final Diagnosis

Non-epileptiform seizure episode.

Non-Epileptiform Seizures

Seizures can be either epileptiform or non-epileptiform. The pathophysiology of epileptiform seizures is an abnormal firing of neurons in the brain. In contrast, the true underlying cause of non-epileptiform seizures (NES) is unknown. However, it is believed that psychogenic factors such as traumatic events, abuse, or other sudden significant changes in one’s life play a role in developing this disorder. NES can also be triggered by systemic disorders like low glucose levels or cardiac arrhythmias. Both types of seizures can present with similar physical characteristics of falling, shaking, decreased responsiveness, and staring into space. The most common type of NES is a dissociative seizure.

The physical examination can help distinguish non-epileptiform from epileptiform seizures. NES tend to be longer in duration than epileptiform seizures (>2 min vs. 1–2 min, respectively). Eye closure during the episode, especially if the practitioner is met with resistance, suggests non-epileptiform activity. The motor movements of NES tend to wax and wane and can include pelvic thrusting, head-turning, and the patient rolling over from side to side. Variations in vital signs such as tachycardia and hypoxia usually are not present in NES ( Table 44.1 ).

Table 44.1

Comparison of epileptiform vs. non-epileptiform seizures

Epileptic seizures	Non-epileptic seizures
• Can have an aura • Synchronous, rhythmic movements of the extremities • Incomprehensible vocalizations • Associated with tongue biting • Non-combative during the episode • Usually, a single episode at a time	• Not associated with an aura • Asynchronous movement of extremities, bizarre movements (head shaking, whole-body shaking, rolling motions) • Rare to see oral injuries, but if they occur, usually to just the tip of the tongue