SEIZURE PEARLS

submitted by Amit Kumar, M.D.

Generalized seizure

-Large parts of bilateral cerebral hemispheres involved
-LOC for the most-part. Post-ictal state (headache, drowsiness) common.
-Examples: Tonic-clonic (grand mal), absence (petit mal), myoclonic, tonic, atonic

Partial seizure

-Simple partial: limited to focal area in single cerebral hemisphere. Usually no post-ictal period.
-Complex partial: simple partial + LOC. Generally associated with an aura (smell, taste, visual hallucination, emotion). Post-ictal period common.

Status epilepticus

-Continuous seizure lasting over 5 mins/more than two discrete seizures without interval recovery

EtOh-withdrawal seizure

-Typically generalized, may begin within 6h of cessation/decreased consumption
-“Kindling phenomenon”: risk and severity of seizure increases (and threshold decreases) with each withdrawal episode

Febrile seizure

-Seizure in child (~3 mo-6y) with associated fever (>38C), without evidence of intracranial infection or other defined cause
-Types: Simple: Generalized, last <15 mins, don’t recur in 24h period; Complex: Focal, last >15 mins, recur in 24h period
-Subsequent epilepsy risk: simple (1-2%, only slightly above general population), complex (~5-10%)

Management

-ABCs, airway, O2, monitor
-If intubating: benzo for induction and short-acting paralytic (succ) to not mask ongoing seizures. Post-intubation sedation: benzo/propofol gtt
-Labs (check for electrolyte disarray, anemia), infectious workup, home anticonvulsant levels, neuroimaging prn
-Check POCG (dextrose for hypoglycemia), probe on abdomen (Mg for eclampsia), check drug-list (Vit B6 for INH toxicity)

Treatment

-Benzodiazepines (enhance GABA-mediated neuronal inhibition): lorazepam (Ativan), diazepam (Valium), midazolam (Versed)
-Phenytoin (reduces repetitive firing of action potentials via Na-channels). Administer IV/PO (rare)
-Fosphenytoin. Administer IV/IM
-Phenobarbital (enhances GABA)
-Valproic acid (increases GABA)

References

-Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976; 295:1029.
-Rosen, Peter, John A. Marx, Ron M. Walls, and Robert S. Hockberger. Rosens emergency medicine: concepts and clinical practice. 8th ed. Vol. 2. Philadelphia: Elsevier Saunders, 2014. (& photo)
-Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). SEIZURE, ADULT. ROSEN & BARKIN’S 5-MINUTE EMERGENCY MEDICINE CONSULT. Retrieved February 13, 2017 from http://www.r2library.com/Resource/Title/1608316300/ch0019s14706