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First-time seizure
From WikEM
Contents
Background
Seizure Types
Classification is based on the international classification from 1981[1]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[2]
Focal seizures
(Older term: partial seizures)
- Without impairment in consciousness– (AKA Simple partial seizures)
- With motor signs
- With sensory symptoms
- With autonomic symptoms or signs
- With psychic symptoms (including aura)
- With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
- Simple partial onset, followed by impairment of consciousness
- With impairment of consciousness at onset
- Focal seizures evolving to secondarily generalized seizures
- Simple partial seizures evolving to generalized seizures
- Complex partial seizures evolving to generalized seizures
- Simple partial seizures evolving to complex partial seizures evolving to generalized seizures
Generalized seizures
- Absence seizures (Older term: petit mal)
- Typical absence seizures
- Atypical absence seizures
- Myoclonic seizure
- Clonic seizures
- Tonic seizures
- Tonic–clonic seizures (Older term: grand mal)
- Atonic seizures
Clinical Features
- Abrupt onset, may be unprovoked
- Brief duration (typically <2min)
- AMS
- Jerking of limbs
- Postictal drowsiness/confusion
Differential Diagnosis
Causes of first-time seizure
- Idiopathic
- Trauma (recent or remote)
- Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
- Structural CNS abnormalities
- Vascular lesion (aneurysm, AVM)
- Mass lesions (primary or metastatic neoplasms)
- Degenerative neurologic diseases
- Congenital brain abnormalities
- Infection (meningitis, encephalitis, abscess)
- Metabolic disturbances
- Hypoglycemia or hyperglycemia
- Hyponatremia or hypernatremia
- Hyperosmolar states
- Uremia
- Hepatic failure
- Hypocalcemia, hypomagnesemia (rare)
- Toxins and drugs
- Cocaine, lidocaine
- Antidepressants
- Theophylline
- Alcohol withdrawal
- Drug withdrawal
- Eclampsia of pregnancy (may occur up to 8wks postpartum)
- Hypertensive encephalopathy
- Anoxic-ischemic injury (cardiac arrest, severe hypoxemia)
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-epileptic seizure
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
Evaluation
Work-up
- POC glucose
- CBC
- Chemistry
- Pregnancy test (female)
- Utox
- Consider LP (if SAH or meningitis/encephalitis is suspected)
- Consider EKG if cardiac origin not ruled out
Indications for Head CT due to Seizure[3]
- If patient has returned to a normal baseline:
- When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure
- Deferred outpatient neuroimaging may be used when reliable follow-up is available
Management
- Protect patient from injury
- If possible, place patient in left lateral position to reduce risk of aspiration
- Do not place bite block!
- Benzodiazepine (Initial treatment of choice)[4]
- Secondary medications
- Fosphenytoin IV 20-30mg/kg at 150mg/min (may also be given IM)
- Contraindicated in pts w/ 2nd or 3rd degree AV block
- Valproic acid IV 20-40mg/kg at 5mg/kg/min
- Levetiracetam IV 60mg/kg, max 4500mg/dose
- Phenobarbital IV 20mg/kg at 50-75mg/min (be prepared to intubate)
- Fosphenytoin IV 20-30mg/kg at 150mg/min (may also be given IM)
- Refractory medications
- Consider
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
Post-Seizure
Several states have mandatory DMV reporting requirements
- No anticonvulsant treatment necessary if patient has[8]:
- Normal neuro exam
- No acute or chronic medical comorbidities
- Normal diagnostic testing (including normal imaging)
- Normal mental status
- Treatment generally indicated if seizure due to an identifiable neurologic condition
Disposition
- Discharge (no need to start antiepileptic[8]) with neuro follow up
- Risk for recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%)
See Also
External Links
References
- ↑ Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
- ↑ Epilepsia 2015; 56:1515-1523.
- ↑ ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625
- ↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
- ↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
- ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
- ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
- ↑ 8.0 8.1 Krumholz A, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology 2015; 84(16):1705-1713.
