Seizure resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]

Definition

A seizure is a temporary un-synchronized electrical activity in the brain. It can manifest as an alteration in mental state, tonic or clonic movements, convulsions, and various other psychic symptoms (such as déjà vu or jamais vu). Recurrent unprovoked seizure is termed as epilepsy.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. The causes by themselves are usually not life threatening.

Common Causes

• Alcohol withdrawal, illicit drugs, Meds(opioids, antidepressants etc.)

Anatomic abnormalities such as Dandy Walker etc.

• Alzheimer's and other degenerative disorders

• Brain tumors, trauma

• Cerebrovascular disease

• Intra-cranial infections

• Metabolic(hypoglycemia, uremia etc.) and electrolyte abnormalities(hyponatremia, hypo/hyperkalemia)

Management

Shown below is an algorithm summarizing the approach to Seizure Management.

Suspected seizure

Initial care: Turn pt. to side Secure airway/assess resp. & cardiac function High conc. O2 Secure IV access

Check labs: Plasma electrolytes Glucose Sr. calcium Tox screen

Buccal midazolam(0.3 mg/kg) /Rectal diazepam(0.2 mg/kg at 5 mg/min) with a past h/o status epilepticus IV lorazepam(0.1 mg/kg at 2 mg/min) if IV access has been established

Ongoing: Lasting > 5 mins or 3 or more seizures in last 1 hr

Suspected alcohol abuse, IV thiamine Supplement IV pyridoxine if suspected pyridoxine def.

Repeat IV lorazepam(0.1 mg/kg at 2 mg/min) after 10 mins

Ongoing

IV phenytoin(20 mg/kg at 50 mg/min + 5-10 mg/kg) or IV fosphenytoin(20 mg/kg PE at 150 mg/min + 5-10 mg/kg) or IV phenobarbital(20 mg/kg at 50–75 mg/min) + 5-10 mg/kg if still seizing 30 mins after onset

Ongoing

Intubate Anesthetize with Midazolam, thiopental or propofol ICU admission

Resolved

Detailed H/o & physical exam

Check labs: AED levels MRI/CT scan 12 lead EEG BUN/Cr. Neuropsychiatric evaluation

Treat with AED if:

Suspected epileptic seizure

Diagnostic doubt

Refer to specialist in 2 weeks

Refer to specialist

Diagnosis by specialist

Uncertain

Epilepsy

Non-seizure disorder

Further investigations

Classify & treat

Refer to psychologist