REBEL Core Cast 36.0 – Seizures

Take Home Points

• When approaching the patient with uspected seizure, focus on questions that matter in determining if the event was a seizure or not
• Extensive lab work after a first time seizure is not necessary in patients who are back to baseline.  Focus on serum glucose, determining pregnancy/postpartum status, and in patients who continue to seize, check that sodium!
• Get a CT of the Head on
  • First-time seizure patients
  • High-risk groups (alcoholics, immunocompromised, infants < 6 months of age)
  • Those with an abnormal neuro exam
  • Those presenting with focal seizures
• Psychogenic non-epileptic seizures are difficulty to distinguish from true epilepsy and there is significant overlap between the two conditions.  Take all seizure activity seriously.
• Give clear discharge instructions to your first-time seizure patients and close the loop on close neurology follow-up.

REBEL Core Cast 36.0 – Seizures

Seizures:

• Definition – an episode of disturbed cerebral functions characterized by excessive and synchronous discharges by cortical neurons
• 2 types
  • Provoked – attributable to an apparent cause (electrolyte disturbance, drug/EtOH withdrawal, eclampsia)
  • Unprovoked – no identifiable cause
• Convulsions – the motor manifestations of the abnormal brain activity
• No single ED test or information from the history is 100% diagnostic of a seizure

Seizure mimics:

• Syncope (20% will be convulsive syncope)
• Convulsive concussion
• Posturing
• Psychogenic non-epileptic spells (PNES)
• certain TIAs
• other neurologic movement disorders

Characteristics that are non-diagnostic of seizure:

• urinary incontinence
• lightheadedness prior to the event
• paresthesias
• activity prior to the event
• headache after
• sustaining an injury

Characteristics that are helpful (make seizure more likely)

• lateral tongue biting
• eyes open during the episode
• post-event confusion
• a forward or unilateral gaze during the episode

First-time seizure ED work-up:

• POC glucose!
  • Most common cause of provoked seizure
• ECG (to rule out dangerous mimics)
• FULL vital signs!
  • temperature, blood pressure, oxygen saturation
• Pregnancy/Postpartum status
  • up to 6 weeks postpartum at risk for eclampsia
• Sodium level
  • especially if seizure is not resolved
• CT of the head
  • may change management in the ED up to 17% of the time
• Let the patient’s medical, social, and medication history dictate any further workup

High-risk groups in which to always get a CTH:

• Those not back to baseline
• Chronic alcohol use
• Immunocompromised
• Infants < 6 months of age
• Those with an abnormal neuro exam
• Those with focal seizures
• Recent neurosurgical intervention/instrumentation

Psychogenic Non-Epileptic Seizures (PNES)

• Involuntary episodes NOT associated with abnormal cerebral discharges
• Often associated with a history of PTSD, abuse
• Triggering event is not usually readily identifiable
• Between 5-60% of patients diagnosed with PNES will ALSO have a concurrent diagnosis of epilepsy
• PNES does not equal malingering

Features of PNES:

• long duration
• gradual onset
• asynchronous movements
• closed eyes
• pelvic thrusting, leg bicycling
• moaning or talking through episode
• side to side head & body movements
• ictal crying
• absence of postictal period
• postictal stertorous breathing

Disposition for first-time seizures:

• If back to baseline, relevant labs and CTH normal, patient can be discharged
• Prompt follow-up with Neurology for EEG should be available
  • sensitivity of the EEG declines the further in time from the episode
• AED prescription/loading is NOT necessary in patients with unprovoked first-time seizures
  • consider (in conjunction with Neurology colleagues) starting an AED in patients at higher risk of recurrent seizure
    • prior stroke or TBI
    • significant neuro-imaging abnormality
    • nocturnal seizure

Discharge instructions:

• No bathing or swimming alone
• No bathing children alone
• No driving until cleared by a neurologist
• Local/state laws differ across the country, but realize that they many require you as the physician to report seizures to the DMV
• Prompt follow-up with a neurologist for EEG

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)