Seizure (2024)

~ iEM Education Project Team

by Ardi Knobel Mendoza, Danielle Charles-Chauvet, Erik J. Blutinger

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Introduction

Seizures are caused by abnormal cortical neuronal activity that manifests as changes in alertness or neurological symptoms. While seizures account for only 1% of all emergency department (ED) visits and 3% of prehospital transports, their potential for significant morbidity undermines the importance of rapid assessment and treatment in emergency settings [1]. The etiology of seizures varies by age group, with the most common causes being fever in infants and metabolic derangements or structural abnormalities in adults over 75. This chapter will explore various seizure presentations, diagnostic assessment tools, and considerations for treatment and disposition decisions in the ED.

You have a new patient!

A 24-year-old female presents to the emergency room after being found on the street. She is minimally responsive, alert, and oriented only to herself. Her heart rate is 87 bpm, blood pressure is 141/94 mmHg, respiratory rate is 14 bpm, and she is afebrile, with oxygen saturation of 99% on room air. She has a gravid uterus with a fundal height of approximately 29 cm (11.4 inches) but is otherwise atraumatic.

a-photo-of-a-24-year-old-female (image was produced by using ideogram 2.0)

What do you need to know?

Seizure Presentation and Classification

It is essential to investigate the cause and categorize the type of seizure after an acute episode to inform the diagnostic and treatment plan. Seizures are often classified as provoked, which occur within 7 days of a neurologic, metabolic, or infectious precipitator, or unprovoked, which has no association with an inciting factor. A history of seizures, febrile illness, malignancy, new medications, recreational drug use, or pregnancy can help to elucidate this. A complete neurological examination, which includes an assessment of mental status, should be performed as an altered postictal state follows most primary seizures. In addition to a change in mental status, the postictal state can present as motor deficits or paresis. Postictal paresis suggests a structural lesion as the cause of the seizure and should prompt cranial imaging [2]. Given that seizures are a manifestation of cortical neuronal activity, the extent of cortical involvement can lead to various symptoms at presentation [3].

Partial seizures involve only some of the cortex. They are classified as either simple, in which the patient is alert throughout, or complex, in which the patient has decreased alertness. Seizures can also begin as partial seizures, involving only some of the cortex, and spread to involve the entire cortex. Seizures involving the entire cortex are termed “generalized” seizures, resulting in decreased alertness. Generalized seizures are further classified based on their physical manifestations:

Absence Seizure: no collapse, automatisms (blinking, staring, lip smacking)

Tonic-clonic Seizure: collapse with stiff non-rhythmic convulsive movements.

Atonic Seizure: collapse without convulsions (similar to syncope) [4].

Febrile seizures typically occur in children 6 months-6 years of age with fevers greater than 38℃ and no neurological infection. 80% of febrile seizures are tonic-clonic in presentation, self-limiting, and do not recur after resolution of the inciting fever [5].

Eclamptic seizures are typically tonic-clonic in presentation and are considered unstable, as they carry significant mortality risk to the mother and fetus. Therefore, any pregnant patient with altered mental status and hypertension, identified as systolic >140 or diastolic >90, should be assessed for eclampsia. In cases with high suspicion of preeclampsia or eclamptic seizures, patients should be treated with magnesium for seizure prophylaxis [6].

Psychogenic seizures present similarly to generalized tonic-clonic seizures but are not associated with cortical neuronal derangements. In the ED, it is difficult to differentiate these seizures from neurogenic seizures, as there is limited access to EEG. However, psychogenic seizures present with more rhythmic and symmetric movements, patients are typically completely aware and conversant throughout, and there is no postictal state.

It is important to consider the duration of a seizure episode in all patients. Most seizures last from 30 seconds to 2 minutes. Seizures lasting longer than 5 minutes meet the criteria for status epilepticus. These patients are considered unstable, as prolonged seizure activity is associated with an increased risk of permanent brain damage. Not all patients with status epilepticus have convulsive seizures, so it is important to assess for subtle symptoms of seizure activity in the unresponsive patient, as they may have non-convulsive status epilepticus—a medical emergency.

Medical History

Thorough history taking in patients with seizure disorders is crucial for accurate diagnosis and effective management. This process involves a structured yet flexible approach to gathering relevant information, ensuring that all aspects of the patient’s condition are considered. Key components of this history include the patient’s medical background, seizure characteristics, and psychosocial factors.

Key Components of History Taking

  • Presenting Complaints: Document the chief complaints, including the nature, frequency, and duration of seizures [7].
  • Seizure Onset and Triggers: Investigate the age of onset, potential triggers (e.g., photosensitivity), and environmental factors that may provoke seizures [8].
  • Medical and Family History: Collect information on past medical history, family history of seizures or neurological disorders, and any relevant social history [7,9].
  • Psychosocial Aspects: Assess the impact of seizures on the patient’s daily life, including emotional and social challenges [8].

A comprehensive history-taking process in seizure patients is crucial for accurate diagnosis and effective management of various seizure types. By gathering essential information regarding seizure semiology, triggers, and patient-specific factors, clinicians can develop tailored treatment strategies to improve outcomes. Seizure semiology, for example, provides valuable insights into the nature of seizures, helping to classify them as either focal or generalized [10]. Detailed accounts of auras and observable signs can further indicate the anatomical origins of seizures, guiding appropriate diagnostic testing [10]. Additionally, identifying seizure triggers, such as environmental factors or specific stimuli, plays a vital role in both diagnosis and management. For instance, patients with photosensitivity may require targeted questions to uncover visual triggers that provoke seizures [8]. Together, these aspects of thorough history-taking form the foundation for effective and personalized seizure management.

When conducting history-taking in patients with seizure disorders, clinicians must be mindful of several common pitfalls that can lead to misdiagnosis or ineffective treatment. These issues often arise from inadequate questioning, overemphasizing certain symptoms, and neglecting the broader context of the patient’s experiences.

Inadequate history-taking, such as missing or incomplete accounts from witnesses, can result in misinterpreting seizure types [11]. Failing to gather detailed descriptions of seizure events, including pre-ictal and post-ictal states, may further obscure the diagnosis [12].

Additionally, an overemphasis on specific symptoms, such as those associated with focal seizures, may mislead clinicians, as these symptoms do not always correlate with the seizure type [13].

Another critical factor is the neglect of contextual elements, such as environmental triggers, which may result in missed diagnoses of reflex seizures, especially in photosensitive patients [8]. Furthermore, ignoring psychosocial aspects and the patient’s overall health can complicate the understanding of seizure disorders [14]. While advancements in technology and neuroimaging provide valuable objective data, the art of listening and thorough history-taking remains an irreplaceable cornerstone in the diagnostic process.

While a comprehensive history is essential, it is also important to recognize that some patients may present atypically, necessitating a tailored approach to history taking that considers individual circumstances and variations in symptom presentation.

Physical Examination

A comprehensive physical examination for patients presenting with seizures in the emergency department is essential for accurate diagnosis and effective management. Key components include a thorough neurological assessment, which involves evaluating consciousness, motor function, and sensory responses to identify any neurological deficits [15]. Monitoring vital signs is equally critical, as instability such as hypotension or tachycardia may indicate underlying issues requiring immediate attention [16]. Additionally, a systematic head-to-toe physical examination can help identify signs of trauma or systemic illness that may contribute to seizure activity [15].

In the emergency department, recognizing physical examination findings indicative of a severe or prolonged seizure episode is critical for timely diagnosis and management, particularly in cases of status epilepticus or non-convulsive seizures. Altered mental status, characterized by confusion, disorientation, or a prolonged postictal state, is a key finding that can suggest non-convulsive status epilepticus (NCSE) [17]. Neurological signs, such as subtle twitching, blinking, or fluctuating sensorium, may also indicate ongoing seizure activity [17]. In cases of generalized tonic-clonic seizures (GTCS), convulsive activity manifests with muscle rigidity and jerking movements, making it a more apparent diagnosis [18]. Additionally, focal seizures can result in specific neurological deficits, which may be misinterpreted as other neurological conditions. While these findings are crucial for identifying severe seizure episodes, it is important to acknowledge that some patients may present with atypical symptoms or lack overt signs of seizure activity, complicating the diagnostic process [17].

While the value of a comprehensive examination cannot be overstated, it is also important to recognize that some patients may present with atypical symptoms or underlying conditions that complicate the diagnosis. This highlights the need for a tailored approach to each case, ensuring that individual factors are carefully considered [16].

Alternative Diagnoses

The diagnosis of seizures primarily relies on the patient’s clinical history, with particular emphasis on accounts provided by witnesses. This is especially important because many seizure types involve impaired consciousness, leaving patients unaware of their episodes. Clinical findings can be supported by interictal electroencephalogram (EEG) abnormalities, although it is essential to note that such abnormalities may also occur in healthy individuals and their absence does not rule out epilepsy. It is equally critical to differentiate seizures from other conditions that may present similarly. These include syncope, such as cardiac arrhythmias or vasovagal episodes; metabolic disturbances like hypoglycemia or hyponatremia; and vascular events such as transient ischemic attacks. Additionally, migraine auras, sleep disorders like narcolepsy or night terrors, movement disorders such as paroxysmal dyskinesia, and gastrointestinal conditions like esophageal reflux in neonates and infants can mimic seizures. Psychiatric conditions, including conversion disorders, panic attacks, malingering, or episodes driven by secondary gain, must also be considered [19].

Acing Diagnostic Testing

When considering diagnostic testing such as labs and imaging, there is a lack of consensus on a set of tests required for all seizing patients. Rather, the diagnostic workup for a patient presenting with a seizure depends on a variety of factors, such as the suspected etiology of the seizure and whether the patient has a known seizure disorder or is presenting with a first-time seizure [20]. In patients with known seizure disorders, it is generally accepted test for levels of the anti-epileptic drug (AED) the patient takes, such as levetiracetam, phenytoin, carbamazepine, phenobarbital, or valproic acid. However, levels can often take hours to days to result or may not be available at a certain facility. In patients without a known seizure disorder, or if there is concern for an etiology for a seizure besides breakthrough from AED treatment, a more extensive workup is warranted. Basic testing should include a finger stick glucose, a urine or serum pregnancy test, and serum chemistry, including calcium and magnesium. Urine/serum toxicologies can also be obtained if there is concern for potential toxic ingestion as a cause. A lactic acid can be obtained, which should be markedly elevated immediately after the seizure and normalize after an hour of seizure onset [21].

A Computed Tomography (CT) Head should be obtained in all first-time seizure patients to assess for a structural lesion such as a mass, a bleed either as the etiology or sequelae of the seizure, or signs of an infection. Seizure sequelae such as significant head trauma can also be assessed with CT imaging to look for a large hematoma or skull fracture in patients who fail to return to baseline mental status after a seizure [22]. Magnetic Resonance Imaging (MRI) can be considered to reveal other diagnoses such as a brain abscess or central vascular event such as infarction; however, this imaging modality is often less available in the emergency setting and may require admission vs. outpatient referral to obtain an image [23]. Electroencephalography (EEG)is when diagnostic testing such as labs and imaging is considered, but there is a lack of consensus on a set of tests required for all seizing patients. Rather, the diagnostic workup for a patient presenting with a seizure depends on a variety of factors, such as the suspected etiology of the seizure and whether the patient has a known seizure disorder or is presenting with a first-time seizure [20]. In patients with known seizure disorders, it is generally accepted test for levels of the anti-epileptic drug (AED) the patient takes, such as levetiracetam, phenytoin, carbamazepine, phenobarbital, or valproic acid. However, levels can often take hours to days to result or may not be available at a certain facility. In patients without a known seizure disorder, or if there is concern for an etiology for a seizure besides breakthrough from AED treatment, a more extensive workup is warranted. Basic testing should include a finger stick glucose, a urine or serum pregnancy test, and a serum chemistry, including calcium and magnesium. Urine/serum toxicologies can also be obtained if there is concern for potential toxic ingestion as a cause. A lactic acid can be obtained, which should be markedly elevated immediately after the seizure and normalize after an hour of seizure onset [21].

A Computed Tomography (CT) Head should be obtained in all first-time seizure patients to assess for a structural lesion such as a mass, a bleed either as the etiology or sequelae of the seizure, or signs of an infection. Seizure sequelae such as significant head trauma can also be assessed with CT imaging to look for a large hematoma or skull fracture in patients who fail to return to baseline mental status after a seizure [22]. Magnetic Resonance Imaging (MRI) can be considered to reveal other diagnoses such as a brain abscess or central vascular event such as infarction; however, this imaging modality is often less available in the emergency setting and may require admission vs. outpatient referral to obtain an image [23]. Electroencephalography (EEG)is an important study in patients who are continuing to have seizures without clear signs of convulsions, such as in nonconvulsive status epilepticus (NCSE), patients with persistent altered mental status, or intubated patients. EEGs are often unavailable in the emergency setting but have a role in the inpatient or ICU settings with neurology consultants [24]. ECGs should also be considered in patients with new-onset seizures to exclude cardiac conduction disorders that can cause seizure-like activity, such as syncope, Brugada syndrome, or QTc prolongation or shortening.

Risk Stratification

The presence of comorbidities plays a critical role in the risk stratification, prognosis, and management of epilepsy, highlighting the need for a holistic approach to patient care. In the emergency department, recognizing these comorbidities is crucial for tailoring immediate interventions and ensuring acute and comprehensive follow-up care. Studies reveal that 60-70% of adults and 80% of children with epilepsy experience multimorbidity [25]. Among patients with senile epilepsy, 81% have at least one comorbidity, with neurological (61%) and cardiovascular (45%) conditions being the most prevalent [26]. Emergency clinicians must remain vigilant for these conditions, as they may exacerbate seizure episodes or complicate acute management. These comorbidities significantly impact seizure outcomes, as patients with neurological and psychiatric disorders face a higher risk of recurrent seizures and reduced likelihood of achieving seizure freedom [26]. Conditions like depression and anxiety are particularly associated with a more severe course of epilepsy [27], and their identification in the emergency setting can guide referrals for further psychiatric evaluation. Additionally, multimorbidity is linked to lower health-related quality of life and increased healthcare costs due to frequent hospitalizations [25]. Cognitive and psychiatric comorbidities often impair daily functioning more than the seizures themselves [28], necessitating a multidisciplinary approach starting from the emergency department. Addressing these comorbidities, however, has been shown to improve overall health outcomes and enhance the quality of life for patients, emphasizing the importance of comprehensive, patient-centered care [28].

Management

The most important intervention in a patient actively seizing is ensuring adequate brain oxygenation. The airway should be protected via maneuvers that include rolling the patient on their side, jaw thrusts, applying a nasopharyngeal airway, applying supplemental oxygen, and preventing aspiration with suction as needed. Oxygenation status should be monitored with continuous pulse oximetry and capnography when possible.

Providers should also anticipate the impending decompensation of the clinical course and the need for intubation by preparing airway equipment, medications, and IV access, which will be discussed later in the chapter. Along with oxygenation, patients must be protected from injury, e.g., from falling out of bed and preventing trauma.

Most seizures stop on their own within one to two minutes of onset, but the longer the seizure lasts, the less likely it is to stop on its own and can become self-sustaining.

Seizures that are continuous or intermittent, lasting more than 5 minutes without recovery of consciousness, are known as status epilepticus. Medical therapies to terminate a seizure are divided into three stages based on escalation of need and inability to terminate the seizure.

Benzodiazepines are considered first-line agents in terminating seizures, followed by second-line agents such as Levetiracetam, Valproate, Phenytoin, and Fosphenytoin [29]. The third-line medications are infusions of benzodiazepines, propofol, or barbiturates, prepared for likely intubation with paralytics and continued infusions [30].

The following lists these medications by stage, dose, and considerations [31, 32]:

Midazolam (1st Line Agent – Benzodiazepine)

  • Loading Dose:
    • 10 mg IM or 0.1-0.2 mg/kg IV.
  • Maintenance Dose: 0.001 mg/kg/min.
  • Pediatric Dose:
    • IV or IN: 0.2 mg/kg (max 5 mg).
    • IM:
      • <13 kg: 0.2 mg/kg.
      • 13-39 kg: 5 mg.
      • 39 kg: 10 mg.
  • Considerations:
    • IM dosing can be used if no IV is established.
    • Acts faster than Lorazepam but has a shorter duration.
    • May cause respiratory depression and hypotension.

Diazepam (1st Line Agent – Benzodiazepine)

  • Loading Dose: 10 mg over 2 minutes. Repeat every 5-10 minutes to a max of 30 mg.
  • Maintenance Dose: N/A.
  • Pediatric Dose: 0.15 mg/kg IV.
  • Considerations:
    • May cause respiratory depression and hypotension.

Levetiracetam (2nd Line Agent)

  • Loading Dose: 60 mg/kg (up to a max of 4,500 mg), infused over 10 minutes.
  • Maintenance Dose: Same as the loading dose.
  • Pediatric Dose: Same as loading dose.
  • Considerations:
    • If the patient weighs >75 kg, the dose is 4.5 g.
    • If seizures stop, continue to give Levetiracetam to prevent recurrence.

Phenytoin (2nd Line Agent)

  • Loading Dose: 18-20 mg/kg with a max rate of 50 mg/min.
  • Maintenance Dose: N/A.
  • Pediatric Dose: N/A.
  • Considerations:
    • Cardiac monitoring is necessary for QRS complex widening.

Fosphenytoin (2nd Line Agent)

  • Loading Dose: 15-20 mg/kg with a max rate of 150 mg/min.
  • Maintenance Dose: Same as loading dose.
  • Pediatric Dose: N/A.
  • Considerations:
    • Cardiac monitoring is necessary for QRS complex widening.

Valproate (2nd Line Agent)

  • Loading Dose: 20-40 mg/kg over 10 minutes. Repeat if needed.
  • Maintenance Dose: Same as loading dose.
  • Pediatric Dose: Same as loading dose.
  • Considerations: N/A.

Propofol (3rd Line Agent)

  • Loading Dose: 1-2 mg/kg IV over 5 minutes (max load 10 mg/kg).
  • Maintenance Dose: 50-80 mcg/kg/min (3-5 mg/kg/hr) as an infusion.
  • Pediatric Dose: N/A.
  • Considerations:
    • May cause respiratory depression and hypotension.

Phenobarbital (3rd Line Agent)

  • Loading Dose: 10-15 mg/kg bolus up to 60 mg/min.
  • Maintenance Dose: 120-240 mg every 20 minutes.
  • Pediatric Dose: N/A.
  • Considerations: N/A.

Midazolam (for 3rd Line use) (3rd Line Agent)

  • Loading Dose: 0.2 mg/kg IV.
  • Maintenance Dose: 0.1-2 mg/kg/hr.
  • Pediatric Dose: N/A.
  • Considerations:
    • Can be used in patients with hypotension.

Once the provider considers 3rd line medications and starting infusions, they should prepare for intubation as the patient is likely in status epilepticus, requiring continued medication and airway protection. Induction medications for intubation are often the same medications listed above in the 3rd stage of treatment, such as propofol or midazolam, and can be on board before paralytics. Paralytics are used to stop the seizure-like activity and aid in intubation, but it is important to remember that they are not meant to terminate the seizure. Patients can still have seizures despite the lack of tonic-clonic seizure activity such as NCSE. Rocuronium is the preferred paralytic agent as it is not associated with the hyperkalemia seen in succinylcholine, which is a risk for patients seizing for an extended period who could develop rhabdomyolysis. Rocuronium paralysis lasts much longer, which should be a consideration when monitoring for further seizures with EEG.

Finally, other conditions can cause seizures or seizure-like activity that require their own treatment strategies, which are discussed below:

Eclampsia, a life-threatening condition often associated with pregnancy, is treated with magnesium to control seizures, benzodiazepines for acute management, and blood pressure control to address underlying hypertension. For seizures due to isoniazid toxicity, the recommended treatment is pyridoxine (vitamin B6), which counteracts the drug’s neurotoxic effects. In cases of hypoglycemia, seizures can be managed by administering Dextrose 50% in Water (D50W) to restore blood glucose levels rapidly. Hypocalcemia, another potential seizure trigger, requires the administration of calcium gluconate or calcium chloride to normalize calcium levels. For seizures induced by hyponatremia, 3% hypertonic saline is used to increase serum sodium levels safely.

In cases of toxicity from aspirin, tricyclic antidepressants (TCAs), or lithium, hemodialysis is indicated to effectively remove the offending agents from the bloodstream. For seizures caused by meningitis, prompt initiation of appropriate antibiotics is critical to address the underlying infection and prevent further complications.

Special Patient Groups

Pediatrics

Seizures in pediatric patients can present with diverse etiologies ranging from febrile seizures to more serious underlying conditions such as intracranial infections, metabolic disturbances, or congenital disorders. In children under 5, febrile seizures are the most common cause of convulsions and are generally self-limited, though they require careful differentiation from more serious causes like meningitis or encephalitis. Clinical reasoning should prioritize a detailed history, including the onset of the seizure, vaccination status, and any family history of epilepsy or neurodevelopmental disorders. Laboratory tests and imaging may be indicated if there is a high suspicion of an underlying structural or metabolic issue, such as in children with a prolonged postictal state or a first-time seizure without a clear precipitant. In the emergency department (ED), rapid assessment of the child’s airway, breathing, and circulation (ABCs) is paramount, along with ensuring the seizure is appropriately controlled, often with medications like lorazepam or diazepam. Close follow-up is necessary to assess for recurrent seizures or potential neurological sequelae.

Geriatrics

Seizures in elderly patients often present a diagnostic challenge due to the overlap with other common age-related conditions, such as syncope, transient ischemic attacks (TIA), or dementia-related behavioral changes. In this population, new-onset seizures should prompt an urgent evaluation for reversible causes, including cerebrovascular events, metabolic disturbances (such as hyponatremia or hypoglycemia), brain tumors, or infections like meningitis or encephalitis. Seizures in older adults may also be a manifestation of progressive neurodegenerative diseases, including Alzheimer’s or Parkinson’s disease. Emergency management in the ED should focus on stabilizing the patient while considering potential drug interactions, as elderly patients are more likely to be on multiple medications that may lower the seizure threshold (e.g., antipsychotics, antidepressants, or antihypertensives). Antiepileptic drug (AED) therapy initiation, while necessary in recurrent or long-duration seizures, must be approached cautiously due to age-related pharmacokinetic changes and the increased risk of side effects. A thorough evaluation for underlying causes, including neuroimaging and laboratory tests, is critical.

Pregnant Patients

Seizures during pregnancy present unique challenges in both diagnosis and treatment. The differential diagnosis includes pregnancy-specific conditions like eclampsia, in addition to the possibility of preexisting epilepsy or new-onset seizures due to metabolic derangements or intracranial pathology. In a pregnant patient with a seizure, the clinical priority is to ensure both maternal and fetal well-being. Eclampsia, a severe complication of preeclampsia, must be ruled out, as it presents with generalized tonic-clonic seizures and may lead to maternal and fetal morbidity if not promptly treated. Once eclampsia is excluded, consideration should be given to other causes such as hypoglycemia, cerebrovascular accidents, or drug toxicity (e.g., withdrawal from anticonvulsant medications). Emergency management in the ED should prioritize seizure control, typically with benzodiazepines, while avoiding teratogenic medications. Magnesium sulfate is the treatment of choice for eclampsia. Fetal monitoring should be initiated, and careful planning for delivery may be required depending on the severity of the condition and gestational age. The clinical approach should balance the need for immediate seizure control while minimizing risks to both the mother and fetus.

When To Admit This Patient

Few definitive practice guidelines are available to emergency physicians making disposition decisions for seizure episodes. However, all critically ill patients must be admitted to the inpatient setting since overall risk assessment is important for deciding whether to safely discharge patients home. For alternative clinical presentations, the physician should reliably assess whether the patient’s overall presentation warrants further medical interventions in a clinical setting.

For emergency physicians, seizure recurrence, morbidity, and mortality are useful measures to consider for safe discharge. Studies suggest that seizure recurrence most often depends upon EEG findings and the underlying cause—normal EEG and undetectable cause are associated with lower recurrence rates [33]. With positive neuroimaging findings (e.g., structural findings), initiating AED therapy for first-time seizures is recommended given a high 1-year recurrence risk of up to 65% [34].

Any patients with abnormal neurologic signs or symptoms who have not fully recovered from their seizure should not be discharged. Other important clinical benchmarks are the presence of normal vital signs, CT head imaging, EKG, basic lab results (especially renal function and blood counts), and follow-up. As part of the physician’s risk assessment of the patient’s overall condition, social factors must also be taken into account: lack of follow-up care, history of being lost to follow-up, and insufficient assistance available at home should all weigh towards admitting the patient for further monitoring (and possible seizure workup).

Generally, stable patients are those who return to their baseline mental status, do not exhibit any new neurological deficits, have no significant lab result abnormalities, and remain at low risk for recurrent seizure activity in the short term. Coordinating reliable follow-up is important, and all patients should be educated about the “red flag” signs and symptoms that warrant urgent evaluation and treatment.

Revisiting Your Patient

Altered mental status in the gravid, hypertensive patient is concerning for eclampsia. This patient should be started on 2mg of Mg as seizure prophylaxis. Obstetrics should be consulted as urgent delivery via cesarean section is the definitive treatment for this patient’s seizures. After delivery, the patient should be monitored closely for postpartum eclamptic seizures, which can occur up to 6 weeks postpartum.

Authors

Picture of Ardi Knobel Mendoza

Ardi Knobel Mendoza

Ardi Mendoza, MD is a resident at the Mount Sinai Hospital Emergency Medicine Program. He is interested in Health System and Emergency System Strengthening and local partner/local government-led collaborations. He has prior experiences in the field of Global Surgery while at Rutgers Robert Wood Johnson Medical School, assessing financial risk protection from impoverishing and catastrophic expenditure due to surgical care in the Colombian Healthcare System. He lived in Lima, Peru for a year working with Peruvian researchers at the University Cayetano Heredia as a research coordinator helping to develop a point-of-care diagnostic screening tool for Autism using eye-tracking technology.

Picture of Danielle Charles-Chauvet

Danielle Charles-Chauvet

Danielle Charles-Chauvet, MD is an Emergency Medicine resident at the Mount Sinai Hospital in New York. She is deeply invested in medical education and health disparities and, in affiliation with Harlem Children's Zone, has led several community-based educational initiatives to address these disparities. She designed and taught a course entitled Health and Structures of Oppression at Brown University's medical school. Her dedication to education earned her the 2022 National Outstanding Medical Student Award from the Academic College of Emergency Physicians and the 2021 Medical Education Award from the Society of Academic Emergency Medicine. She is currently working to expand her impact internationally by building Haiti's medical education infrastructure.

Picture of Erik J. Blutinger

Erik J. Blutinger

Erik J. Blutinger, MD, MSc, FACEP is a full-time emergency physician at Mount Sinai Queens Hospital in New York City and Medical Director to the Community Paramedicine program at Mount Sinai Health Partners. He completed his residency training at the University of Pennsylvania, Master's at the London School of Hygiene & Tropical Medicine, and has worked on a variety of health initiatives in quality and patient experience with formal leadership training in Quality Improvement (QI). Erik has worked in multiple national healthcare systems and underserved communities, including townships in South Africa and Guatemala, Bhutan, India, and Austria.

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References

  1. Jagoda, (2010). Seizures: An issue of Emergency Medicine Clinics. Elsevier Saunders.
  2. Werhahn, J. (2010). Weakness and focal sensory deficits in the postictal state. Epilepsy & Behavior, 19(2), 138–139. https://doi.org/10.1016/j.yebeh.2010.06.029
  3. Kim, , Cho, J.-W., Lee, J., Joo, E. Y., Hong, S. C., Hong, S. B., & Seo, D.-W. (2011). Seizure duration determined by subdural electrode recordings in adult patients with intractable focal epilepsy. Journal of Epilepsy Research, 1(2), 57–64. https://doi.org/10.14581/jer.11011
  4. Kumar, , Sharma Maini, K., & Arya, K. (n.d.). Simple partial seizure. National Center for Biotechnology Information. Retrieved April 10, 2023, from https://pubmed.ncbi.nlm.nih.gov/29763181/
  5. Heon, (n.d.). Febrile seizures. Core EM. Retrieved April 10, 2023, from https://coreem.net/core/febrile-seizures/
  6. Wagner, K. (2004, December 15). Diagnosis and management of preeclampsia. American Family Physician. Retrieved April 10, 2023, from https://www.aafp.org/pubs/afp/issues/2004/1215/p2317.html
  7. Hiroshi, S., Hallett, M., ‘History taking’, The Neurologic Examination: Scientific Basis for Clinical Diagnosis, 2 edn (2022; online edn, Oxford Academic, 1 Aug. 2022), https://doi.org/10.1093/med/9780197556306.003.0002, accessed 1 Dec. 2024.
  8. Brinciotti, M., Bouilleret, V, Masnou, P. (2021). Optimizing the Patient’s History: A Modern Approach. 10.1007/978-3-319-05080-5_26.
  9. Dulak SB. A practical guide to a thorough history. RN. 2004;Suppl:14-21.
  10. Wolf P, Benbadis S, Dimova PS, et al. The importance of semiological information based on epileptic seizure history. Epileptic Disord. 2020;22(1):15-31. doi:10.1684/epd.2020.1137
  11. Smith PE. If it’s not epilepsy… J Neurol Neurosurg Psychiatry. 2001;70 Suppl 2(Suppl 2):II9-II14. doi:10.1136/jnnp.70.suppl_2.ii9
  12. Trevathan E. Patient page. The diagnosis of epilepsy and the art of listening. Neurology. 2003;61(12):E13-E14. doi:10.1212/wnl.61.12.e13
  13. Henry JC. Comment: Be careful what you ask when interviewing patients with epilepsy. Neurology. 2015;85(7):594. doi:10.1212/WNL.0000000000001843
  14. Kanner, A. (2008). Common Errors Made in the Diagnosis and Treatment of Epilepsy. Seminars in neurology. 28. 364-78. 10.1055/s-2008-1079341.
  15. Wan, XH & Zeng, R. (2020). Handbook of Clinical Diagnostics. 10.1007/978-981-13-7677-1.
  16. Bank, A & Bazil, C. (2019). Emergency Management of Epilepsy and Seizures. Seminars in Neurology. 39. 073-081. 10.1055/s-0038-1677008.
  17. Hasan, Ahmed. (2016). Non-Convulsive Status Epilepticus in Emergency Department: A Diagnostic Challenge. Journal of Medical Science And clinical Research. 10.18535/jmscr/v4i8.103.
  18. Virani, D., Sangani, S., Patel, C, Patel, V., Saha, J., Kalsariya, R. (2024). 5. Study of Clinical Profile, Management and Outcome of Patients Presented with Seizures in Emergency Medicine Department. BJ Kines: National Journal of Basic & Applied Sciences, doi: 10.56018/bjkines2024065
  19. Ko DY. Epilepsy and Seizures Differential Diagnoses (updated Jul 26, 2002). From https://emedicine.medscape.com/article/1184846-differential?&icd=login_success_email_match_fpf Accessed: Nov 1,
  20. Burgess M, Mitchell R, Mitra B. Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review. Acad Emerg Med. 2022 May;29(5):649-657. doi: 10.1111/acem.14391. Epub 2021 Oct 1. PMID: 34534387.
  21. Teran F, Harper-Kirksey K, Jagoda A. Clinical decision making in seizures and status epilepticus. Emerg Med Pract. 2015 Jan;17(1):1-24.
  22. Harden CL, Huff JS, Schwartz TH, Dubinsky RM, Zimmerman RD, Weinstein S, Foltin JC, Theodore WH; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Oct 30;69(18):1772-80. doi: 10.1212/01.wnl.0000285083.25882.0e. PMID: 17967993.
  23. Gelisse P, Crespel A, Genton P, Jallon P, Kaplan PW. Lateralized Periodic Discharges: Which patterns are interictal, ictal, or peri-ictal? Clin Neurophysiol. 2021 Jul;132(7):1593-1603. doi: 10.1016/j.clinph.2021.04.003. Epub 2021 Apr 27. PMID: 34034086.
  24. Rosenthal Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn). 2021 Oct 1;27(5):1321-1343. doi: 10.1212/CON.0000000000001012. PMID: 34618762.
  25. Gaitatzis A, Majeed A. Multimorbidity in people with epilepsy. Seizure. 2023;107:136-145. doi:10.1016/j.seizure.2023.03.021
  26. Cao, Z., Li, Y., Liu, S. et al.Clinical characteristics and impact of comorbidities on the prognosis of senile epilepsy in Southwest China: a retrospective cohort study. Acta Epileptologica 6, 11 (2024). https://doi.org/10.1186/s42494-024-00153-8
  27. Kanner, A.M., Ribot, R. and Mazarati, A. (2018), Bidirectional relations among common psychiatric and neurologic comorbidities and epilepsy: Do they have an impact on the course of the seizure disorder?. Epilepsia Open, 3: 210-219. https://doi.org/10.1002/epi4.12278
  28. Mula M, Coleman H, Wilson SJ. Neuropsychiatric and Cognitive Comorbidities in Epilepsy. Continuum (Minneap Minn). 2022;28(2):457-482. doi:10.1212/CON.0000000000001123
  29. Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012 Feb 16;366(7):591-600. doi: 10.1056/NEJMoa1107494. PMID: 22335736; PMCID: PMC3307101.
  30. Falco-Walter JJ, Bleck Treatment of Established Status Epilepticus. J Clin Med. 2016 Apr 25;5(5):49. doi: 10.3390/jcm5050049. PMID: 27120626; PMCID: PMC4882478.
  31. Brophy GM, et : Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 17:3-23, 2012.
  32. Seizure: Emergency Medicine, Second Editor; Adams, James G., MD, 2013, 2008 by Saunders, an imprint of Elsevier Inc. Book Chapter 99
  33. Berg AT, Shinnar The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991;41:965–72.
  34. Jagoda A; Gupta, K. “The Emergency Department Evaluation of the Adult Patient Who Presents with a First-Time ” Emergency Medicine Clinics of North America, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/21109101/.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

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