Medical noncompliance (most common cause of recurrent seizure)Įtiologies of secondary, or reactive, seizures include:.Patients with a primary seizure disorder are more prone to seize in the setting of: Seizures may occur either as a primary seizure disorder, generally referred to as epilepsy, or as a reaction to other underlying conditions. Physical exam may reveal a twitching/seizing limb, but absence of visible convulsions does not rule out ongoing seizure activity in the patient with a depressed mental status. A prolonged postictal period may also indicate ongoing seizure activity. Status epilepticus is present in any patient with a seizure of greater than 5 minutes duration or 2 or more seizures in a row without a return to baseline. These findings may suggest alcohol withdrawal, drug use, or hypoglycemia as possible causes of seizure. Patients may also have tachycardia, diaphoresis, tremulousness, and/or anxiety. However, this is a diagnosis of exclusion, and the patient should undergo work-up for other causes of the paralysis. A focal neurologic deficit mimicking a stroke, referred to as Todd’s paralysis, may also be present. Minor head trauma may be present but does not help to distinguish between seizures and other etiologies. Common findings include postictal confusion that resolves while in the ED, evidence of tongue trauma from biting, and urinary or bowel incontinence. While history will guide the physician in most cases of seizures, physical exam can provide some clues to make the diagnosis more likely. Rarely, patients who have had seizures will present to the ED having been “found down” without a clear cause of their loss of consciousness.įactors that suggest that a seizure has occurred include: Seizures may also be unwitnessed and a patient may present to the ED stating that they woke up confused or on the floor. When the patient awakens, witnesses or EMS will report that they were confused for several minutes before they returned back to baseline (postictal state). Most seizures last 1-2 minutes, but duration can be highly variable. Focal seizures may generalize to involve both cerebral hemispheres, referred to as partial seizures with secondary generalization.Ĭlassically, patients are brought to the ED after a witnessed seizure. Focal seizures are referred to as simple partial seizures when cognition is not impaired and as complex partial seizures when cognition is impaired. Seizures result from abnormal, excessive activity of the CNS and are categorized as either generalized, involving both hemispheres of the brain with loss of consciousness, or focal (partial), in which only one hemisphere is involved. Patients with status epileptics have increased morbidity and mortality. Status epilepticus is a life threatening emergency and is responsible for 50,000-150,000 visits per year to the ED. people, and 1% of the population will experience at least one seizure in their lifetime. Seizures are a common reason why patients present to the Emergency Department, with over 2.5 million visits per year (approximately 1-2% of all ED visits). Describe appropriate management of status epilepticus.Discuss the work-up and disposition of patients presenting with recurrent seizures.Discuss the work-up and disposition of a new-onset, first-time seizure.List the differential diagnosis of seizure.Upon completion of this self-study module, you should be able to: During evaluation the patient begins to shake which progresses to a generalized tonic-clonic seizure. On exam the patient is somnolent with a GCS of 10 and does wake with noxious stimuli, however she is unable to provide additional history and is unable to cooperate further with exam. Initial vital signs are BP 103/67, HR 118, RR 20, SpO2 94% on RA. Friends report that she takes medicine for a medical condition, but they are not sure what. Per EMS report, the friends stated that she had 3 seizure like episodes that lasted approx 1 min each with approx 15 minutes in between episodes. University of IowaĪ 21 year old female with unknown medical history presents by EMS for evaluation of seizure like activity. Rush UniversityĮditor: Olivia Bailey, MD. SAEMF/CDEM Innovations in Undergraduate Emergency Medicine Education GrantĬareer Development and Mentorship CommitteeĬommunications and Social Media CommitteeĬDEM Medical Education Fellow Travel ScholarshipĪuthor: G. Presidential Address: Where Do We Go From Here?ĮMF/SAEMF Medical Student Research Training Grant Virtual Rotation and Educational ResourcesĬommittee Update: NBME EM Advanced Clinical Examination Task Force Visit us on Twitter LinkedIn Facebook YouTubeĮffective Consultation in Emergency Medicine Video
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