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.

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:

Characteristics that are non-diagnostic of seizure:

Characteristics that are helpful (make seizure more likely)

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:

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:

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)

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