Definitions

• Seizure: abnormal electrical brain activity that may cause a clinical event
• Provoked: identifiable cause (hypoglycemia, trauma, etc.)
• Unprovoked: no identifiable external cause
• Focal: one region/hemisphere
• Aware (simple partial) or impaired awareness (complex partial)
• Generalized: bilateral involvement, often a/w altered consciousness/awareness
• Focal may progress to generalized
• Epilepsy: 2 spontaneous seizures separated by at least 24 hrs, or one unproved seizure and test findings that significantly raise the risk of further spontaneous seizures
• Event/spell/paroxysm/episode: transient symptoms
• Status epilepticus: continuous seizure activity for > 5 min, or back-to-back seizures without a return to baseline in between

History

• Aura - warning signs, initial symptoms
• Rising epigastric sensation, nausea, olfactory/gustatory hallucination, etc.
• Timing (age of onset, inciting event, sudden onset, duration (nearly all < 3 min), frequency)
• Movements (tonic, clonic, myoclonic (jerking), tonic-clonic, atonic/astatic), automatisms, head/eyes/arms > legs, arrest of behavior
• Altered consciousness/awareness (ictal, post-ictal)
• Incontinence, tongue biting, unilateral weakness, unexplained injuries, falls
• Drugs/toxins/exposures
• Other medical problems
• Full general/neuro exam

Seizure mimics

• Syncope, migraine, TIA, sleep disorders, psychogenic nonepileptic seizure (pseudoseizure)

Labs to identify causes of provoked seizure

• Finger stick glucose (hypoglycemia may be cause)
• BMP for electrolyte derangements (Na, Ca, Mg, Phos)
• Lactic acidosis, ↑ WBC may be seen after seizure
• Imaging
• Acute - head CT
• Brain MRI may be indicated
• STAT EEG if concern for status epilepticus
• Other testing as indicated
• UDS/Narcan
• Drug levels if on anti-epileptics
• Give thiamine
• TSH, HIV, hCG, CSF, video EEG

When are anti-epileptic drugs (AEDs) indicated?

• Unprovoked single seizure
• Normal EEG and brain imaging (head CT +/- brain MRI) - 25% chance of having another unprovoked seizure; can offer AED
• If either abnormal, should be on AEDs

Status epilepticus

• All cause mortality 30%
• Consider non-convulsive status if patient not improving after 20-30 min, or still abnormal mental status 60 min after tx - repeat EEG
• Treatment algorithm
• Lorazepam (Ativan) 4 mg IV push over 2 min
• Midazolam (Versed) 10 mg IM if no IV access
• If still seizing after 5 min, repeat x 1
• If seizures continue
• Rapid sequence intubation w/ short-acting paralytic, avoid etomidate (why?)
• Midazolam
• AND fosphenytoin/phenytoin or valproate
• Fosphenytoin can be loaded/infused faster than phenytoin (risk of ___)