Always check a bedside glucose level in seizure patients.
Monitor airway, breathing, and circulation in actively seizing patients and intervene when needed.
Intravenous lorazepam is the drug of choice for actively seizing patients.
Search for a secondary cause of seizures in first-time seizure patients and those with a known seizure disorder who have new or different features.
A seizure is an episode of abnormal neurologic function caused by inappropriate, excessive activation of neurons in the brain. Seizures account for up to 2% of emergency department (ED) visits and affect approximately 4 million people in the United States. The incidence of seizures is highest among those <20 and >60 years of age. Status epilepticus is continuous or intermittent seizure activity for more than 5 minutes without recovery of consciousness. It has a mortality rate of up to 20%. Half of all patients presenting to the ED in status epilepticus have no prior history of seizures. ED management of seizures should focus on cessation of seizure activity.
Seizures result from abnormal excitation or lack of inhibition of neurons in the brain. The cause may be primary (idiopathic) or secondary, with an underlying etiology that may be treatable such as hypoglycemia. In patients with a known seizure disorder, the most common cause of recurrent seizures includes medication noncompliance, sleep deprivation, alcohol or substance withdrawal, and infection. Secondary causes of seizures include head trauma, stroke, intracranial infection or mass, electrolyte abnormalities, alcohol withdrawal, drug overdose, and eclampsia.
Seizures are classified as generalized or partial. Generalized seizures are characterized by excitation of the entire cerebral cortex and always cause alteration of mental status. Generalized seizures can manifest as a staring spell (absence or petit mal), diffuse motor activity (tonic-clonic or grand mal), or drop attacks (myoclonic, tonic, clonic, or atonic). The postictal period refers to the time (lasting up to 1 hour) after a generalized seizure when the patient gradually returns to baseline mental status. The postictal period often distinguishes generalized seizures from other causes of sudden altered mental status such as syncope.
Partial seizures are caused by localized neuronal activation that may remain localized or spread to involve other areas of the brain (referred to as partial seizure with secondary generalization). Patients with simple partial seizures experience brief focal motor or sensory symptoms without altered mental status. Complex partial seizures are characterized by altered consciousness with autonomic, sensory, motor, and/or psychological manifestations (Table 83-1).
Classification of seizures.
| Generalized Seizures (always loss of consciousness) |
| Tonic-clonic seizures (grand mal) |
| Absence seizures (petit mal) |
| Myoclonic seizures |
| Clonic seizures |
| Atonic seizures |
| Partial (focal) Seizures |
| Simple partial (no alteration of consciousness) |
| Complex partial (impaired consciousness) |
| Partial seizures (simple or complex) with secondary generalization |
While the history is performed, obtain a blood glucose level in all patients with altered mental status, including those suspected of having had a seizure. Hypoglycemic seizures are easily treated with dextrose and do not respond to standard antiepileptic drugs. To determine whether a seizure actually occurred, gather a complete and detailed history from witnesses, emergency medical service, and the patient. Note the onset of symptoms, the presence of a prodrome or aura, loss of consciousness, diffuse or focal motor activity, bowel or bladder incontinence, length of the event, and postictal period. Ask about recent trauma (head injury), headaches (mass lesions), pregnancy (eclampsia), history of metabolic abnormalities such as diabetes (hypoglycemia), drug ingestions (tricyclic-antidepressants, isoniazid), alcohol use (withdrawal seizure), and sleep disturbances. If the patient has a known seizure disorder, obtain a description of the patient’s typical seizure pattern and medication history.
As with any high-acuity patient, perform a primary survey of the patient, assessing airway, breathing, and circulation (ABCs), vital signs, bedside glucose level, basic mental status, and pupillary symmetry and reactivity. In most patients, the seizure will stop spontaneously within 2 minutes, and the initial postictal period will result in profound alteration of mental status. At this time, manage the airway by using jaw thrust/chin lift, repositioning the patient’s head, or inserting a nasopharyngeal airway. Look for physical examination signs of toxidromes (eg, sympathomimetic), trauma (abrasions, contusions, fractures), increased intracranial pressure (papilledema or Cushing reflex), and any focal neurologic abnormality that would indicate a secondary cause of seizure. A complete neurologic examination should be performed as soon as possible. Transient focal muscle paralysis after a seizure is known as Todd paralysis and usually resolves within 24–48 hours. Up to 25% of patients with a generalized seizure sustain a tongue laceration, usually of the lateral tongue. Tongue biting has a 99% specificity and 24% sensitivity for diagnosis of generalized tonic-clonic seizure.
