Focal Seizure

Patient with h/o epilepsy presents with acute onset shaking/jerking. Event lasted < 3 minutes and preceded by visual distortion, perception of flashing lights, unilateral extremity numbness/tingling; symptoms s/p event include H/A. Witnesses describe shaking/jerking that proceeded distally to caudally along affected extremity. Patient displayed facial grimacing, chewing/lip smacking, word repetition during even. Confusion, unilateral weakness on exam.

• Obtain FS glucose, CBC, CMP, magnesium/phosphorus level, U/A, urine drug screen

• Imaging

  • New onset seizure: Obtain MRI to evaluate for structural lesion, ischemic stroke

  • Obtain EEG to evaluate for interictal spikes

  • Consider video-EEG monitoring

• Treatment

  • Correct any underlying metabolic derangements

  • If seizure does not remit within 5 minutes, initiate status epilepticus protocol

  • Continue current seizure prophylaxis

  • Consult neurology

• Counseling

  • Pt counseled about driving restrictions, seizure precautions

  • Pt advised to keep a seizure calendar including seizure events and potential provoking factors

Notes

• Jacksonian march classically described as numbness/tingling in face, hand, or foot followed by jerking in affected extremity of face

• Todd paralysis: Unilateral paralysis following unilateral focal motor seizure

• Evaluation for interictal spikes has poor sensitivity

Generalized Seizure

Pt with h/o hyperthyroidism, DM, traumatic brain injury, alcohol/benzodiazepine abuse and recent meningitis/encephalitis presents with acute loss of consciousness preceded by a screaming/choking sound. Bystanders report initial arm stiffening/cyanosis followed by jerking/switching, frothy sputum production, urinary incontinence. Event lasted < 5 minutes and followed by confusion, suppressed awareness. Fever, confusion, weakness on exam.

• Labs

  • Obtain fingerstick glucose, CBC, CMP, magnesium/phosphorus level, urinalysis, urine drug screen

  • Consider lumbar puncture to r/o infection

• Imaging

  • Obtain head CT to r/o intracranial hemorrhage, evaluate for intracranial lesions

  • Obtain MRI to r/o ischemic stroke

  • Consider video-EEG monitoring

• Treatment

  • Correct any underlying metabolic derangements

  • If seizure does not remit within 5 minutes, initiate status epilepticus protocol

  • Consult neurology

• Seizure Prophylaxis

  • First provoked seizure: No seizure prophylaxis indicated

  • Repeat provoked seizure or first unprovoked seizure: Discuss risks and benefits of seizure prophylaxis

  • Repeat unprovoked seizure: Start seizure prophylaxis per neurology recommendations

• Counseling

  • Pt counseled about driving restrictions, seizure precautions

  • Pt advised that 33% of adults with an unprovoked seizure will have recurrent seizure within 5 years

  • Pt advised to keep a seizure calendar including seizure events and potential provoking factors

Notes

• Seizures may be precipitated by metabolic disturbances, e.g. hypoglycemia, hyperglycemia, hyponatremia, hypomagnesemia, hypocalcemia, hyperthyroidism, uremia, withdrawal, acute intoxication

• Driving restrictions may vary by state or province

Status Epilepticus

Pt with h/o generalized convulsive seizures presents actively seizing. Witnesses report 2 seizure episodes without complete recovery of consciousness in between. Current seizing episode has lasted longer than 5 minutes. Bilateral tonic stiffening with unilateral, rhythmic muscle jerking on exam.

• Initial action

  • Obtain vital signs

  • Respiratory compromise: Initiate oxygen +/- mechanical ventilation

  • Start continuous cardiac monitoring with pulse oximetry

  • Establish two IV catheters

  • Obtain fingerstick glucose, CBC, CMP, magnesium/phosphorus level, U/A, urine drug screen

• Initiate treatment

  • Correct metabolic abnormalities

  • In first IV line: Administer lorazepam 2mg IV q1 minute while blood pressure remains >90/>60

  • In second IV line

    • Administer fosphenytoin 20 mg PE/kg at 100mg PE/min

    • Repeat dose 5 mg PE/kg at 100 PE/min if seizure continues

• Refractory status epilepticus

  • Midazolam 0.2mg/kg IV bolus at 2mg/min followed by 0.1mg/kg/hr infusion; titrate infusion until seizures stop (max 3 mg/kg/hour)

  • If seizure continues s/p 1 hour midazolam treatment, start propofol

  • If seizure continues s/p 1 hour propofol, start phenobarbital

• Patient's family counseled that status epilepticus may lead to alteration of neuronal networks and/or neuronal injury/death

Note: Patients in focal motor status epilepticus may present without impaired consciousness