Seizure

Key considerations: Status epilepticus (seizure >5 minutes), Meningitis / Encephalitis, Intracranial hemorrhage

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history: Witnessed vs unwitnessed — description of event from witnesses; Duration, focal onset, tonic-clonic activity, tongue biting, incontinence; Post-ictal state: confusion, Todd paralysis; Known seizure disorder and medications — compliance?; Alcohol use: last drink (withdrawal), amount; Triggers: sleep deprivation, medications, drugs, flashing lights; Pregnancy status; exam: Mental status: postictal confusion duration; Lateral tongue bite (specific for generalized seizure); Head trauma from fall; Focal neurological deficits: Todd paralysis (transient, resolves); Signs of substance use or withdrawal; Fundoscopic: papilledema (mass lesion, IIH); labs: Point-of-care glucose — first and immediate; BMP: sodium (hyponatremia), calcium, magnesium; CBC; Antiepileptic drug levels if on medications; Urine drug screen; Prolactin (elevated 10-20 min post-seizure — supports true seizure vs PNES); Pregnancy test if applicable; Ammonia, liver function if liver disease suspected; imaging: CT head non-contrast: first seizure in adult, focal seizure, trauma, anticoagulated, persistent altered mental status; MRI brain: outpatient for first seizure — better for structural causes; CT angiography if stroke or vascular malformation suspected; bedside: Point-of-care glucose; Temperature: febrile seizure (peds), meningitis; Cardiac monitor: arrhythmias can mimic seizures

immediate: Protect airway — position laterally (recovery position), suction; Do NOT place anything in the mouth; Check glucose immediately — treat hypoglycemia with D50; Time the seizure — if >5 minutes, initiate status epilepticus protocol; general: Benzodiazepines for active seizure: midazolam 10mg IM, lorazepam 4mg IV, or diazepam 10mg IV; Monitor for recurrence; Identify and treat underlying cause; specific: diagnosis: First Seizure (Adult); steps: CT head non-contrast in ED; Basic labs: BMP, CBC, glucose; Neurology follow-up for MRI and EEG; Discuss driving restrictions per state law; Decision to start AED usually deferred to neurology; diagnosis: Status Epilepticus; steps: See Status Epilepticus protocol; Benzodiazepine → levetiracetam or fosphenytoin → if refractory: propofol or midazolam drip; Intubation if airway compromised or refractory; Search for cause: infection, metabolic, structural, toxin; diagnosis: Alcohol Withdrawal Seizure; steps: Benzodiazepines: lorazepam or diazepam; Alcohol withdrawal seizures typically occur 6-48 hours after last drink; Risk of progression to delirium tremens — monitor closely; Thiamine 100mg IV before glucose; diagnosis: Eclampsia; steps: Magnesium sulfate 4-6g IV loading dose; Left lateral decubitus position; Definitive treatment is delivery; OB/GYN emergent consult

admit: Status epilepticus; Persistent altered mental status; New structural lesion on CT; Seizure due to metabolic cause requiring treatment; Alcohol withdrawal with risk of DTs; Eclampsia; discharge: Known epilepsy with single breakthrough seizure, therapeutic drug levels, return to baseline; First seizure with normal CT, normal labs, return to baseline mental status, reliable follow-up; Neurology follow-up within 1-2 weeks for MRI and EEG; consults: Neurology: first seizure, refractory epilepsy, status epilepticus; Neurosurgery: structural lesion, AVM, tumor; OB/GYN: eclampsia

Status epilepticus = seizure lasting >5 minutes or recurrent seizures without return to baseline — treat aggressively
Lateral tongue bite is very specific for generalized seizure (vs psychogenic)
Todd paralysis: transient focal weakness lasting minutes to hours post-seizure — resolves completely. If it persists, consider stroke
Alcohol withdrawal seizures occur 6-48 hours after last drink — if >48 hours, look for other cause
First seizure in an adult: always get a CT head in the ED. MRI and EEG can be outpatient if CT is normal

AAN First Seizure Guidelines 2015, Neurocritical Care Society Status Epilepticus Guidelines 2012. Last reviewed: 2024-11-01