Seizures are sudden, uncontrolled electrical disturbances in the brain. The presentation can vary from uncontrolled jerking movement (tonic-clonic seizures) to something as subtle as a momentary loss of awareness (absence seizure).
An epileptic seizure is a transient occurrence of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. Epilepsy is not a single disease, but rather a collection of disorders that have in common the epileptic seizure event.
2 or more unprovoked seizuresTriggers for seizures include:
Risk factors include:
Status epilepticus is defined as when there is more than 5 minutes of a continuous seizure OR there are 2 or more discrete seizures in which there is incomplete recovery of consciousness. Lorazepam is the first line in-hospital treatment for status epilepticus.
A pratical definition of epilepsy is if the patient meets 1 of the following:[1]
2 unprovoked (or reflex) seizures occurring greater than 24 hours apart1 unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 yearsSeizures can either be generalized or focal (partial). Any focal seizure can evolve into a bilateral convulsive seizure. A focal seizure usually evolves into a bilateral seizure when the head begins to turn to the direction contralateral to the hemisphere of seizure origin.
Focal seizures are:
Focal seizures can be further classified into:
Generalized seizures involve both cerebral hemispheres. There are 6 types of generalized epileptic seizures:
15 seconds[2])Taking a history for seizures is important, as this will help you determine the etiology and type of seizure.
Mesial temporal sclerosis (or hippocampal sclerosis) is scarring in the inner portions of the temporal lobe, especially in the CA1 and CA2 regions of the hippocampus. It is the most common pathological finding in patients with intractable temporal lobe epilepsy (TLE).[4]
Focal cortical dysplasias (FCD) are a heterogeneous group of disorders of cortical formation, which are one of the most common causes of epilepsy and can be associated with hippocampal sclerosis and cortical glioneuronal neoplasms.[5]
Ensure the ABCs are monitored closely and that supplemental oxygen is available. Make sure the patient is not at risk of falling, and remove restrictive clothing. Do not place anything in the patient’s mouth unless it is a bite block or an oropharyngeal airway (OPA) to protect the tongue.
First-line treatment is with benzodiazepines IV until seizures are controlled:
If there is difficulty with IV access, lorazepam, midazolam, and diazepam can all be given IM. PR delivery can also be considered. PO benzodiazepines should not be used unless they are alert and have a normal mental status.
| Medications | Management |
|---|---|
| • Lorazepam 2-4mg IV push • If ongoing seizure activity after 5 minutes, repeat x1, give phenytoin 20mg/kg, give simultaneously | • ABCs • Pin prick blood glucose • Thiamine 100mg IM/IV prior to administrations of dextrose • Give 1 amp D50W if glucose low or unknown • Cardiac monitor • Obtain bloodwork |
| • If ongoing seizure activity, consult ICU for intubation and infusion of either: midazolam OR propofol | • Give bolus medications until seizure stops • For breakthrough seizures, re-bolus and increase rate of infusions • Begin continuous EEG monitoring if IV infusion used or patient does not wake up rapidly with resolution of convulsions |
| • For ongoing seizure activity, add additional agents via IV or NG tube, e.g. - valproate, levetiracetam, phenobarbital • Phenytoin (Dilantin) is given as a secondary drug to prevent recurrent seizures, because of lorazepam's short half life | • Obtain neuroimaging when convulsions stop • Consider lumbar puncture/antibiotics if there is a clinical suspicion of infection |