Seizures are a common neurological emergency encountered in the emergency department (ED). They result from abnormal electrical activity in the brain and can present in various forms, ranging from brief lapses in attention to full-body convulsions. As a junior doctor in emergency medicine, understanding the types, causes, assessment, and management of seizures is crucial for providing effective patient care.
Understanding Seizures
Seizures can be classified into two main categories:
1. Focal Seizures
Originate in one specific area of the brain.
May involve motor, sensory, autonomic, or psychic symptoms.
Can progress to generalized seizures.
2. Generalized Seizures
Involve both hemispheres of the brain.
Include various types such as tonic-clonic (grand mal), absence (petit mal), myoclonic, and atonic seizures.
Common Causes of Seizures
Acute Provoked Seizures
Metabolic Disturbances: Hypoglycemia, hyponatremia, hypocalcemia.
Infections: Meningitis, encephalitis.
Toxicologic Causes: Alcohol withdrawal, drug overdose or withdrawal.
Trauma: Head injury.
Cerebrovascular Events: Stroke or transient ischemic attack (TIA).
Unprovoked Seizures
Often indicative of epilepsy if recurrent without an identifiable acute cause.
Structural brain abnormalities or genetic predispositions.
Initial Assessment and Management
History Taking
A thorough history is essential to guide further evaluation:
Description of the seizure event (e.g., duration, type of movements, postictal state).
Presence of any aura or warning signs before the seizure.
Previous history of seizures or epilepsy.
Recent changes in medications or potential triggers (e.g., sleep deprivation, alcohol use).
Family history of seizures or neurological disorders.
Physical Examination
The physical examination should focus on identifying signs that may indicate specific causes:
Neurological examination: Assess for focal neurological deficits or altered mental status post-seizure.
General examination: Look for signs of head trauma or tongue biting.
Diagnostic Workup
Depending on clinical suspicion from history and examination, the following tests may be considered:
Blood Tests: Electrolytes, glucose levels, renal function tests, and toxicology screen if substance use is suspected.
Electrocardiogram (ECG): To rule out cardiac causes if syncope is a consideration.
Imaging: CT scan of the head to rule out structural causes such as hemorrhage or mass lesions.
Management Strategies
Management of seizures in the ED focuses on immediate stabilization and addressing underlying causes:
Immediate Care:
Ensure airway patency and provide supplemental oxygen if needed.
Protect the patient from injury during convulsions by ensuring a safe environment.
Termination of Seizure Activity:
Administer benzodiazepines (e.g., lorazepam) for acute seizure termination if prolonged (>5 minutes) or recurrent seizures occur (status epilepticus).
Address Underlying Causes:
Correct metabolic disturbances such as hypoglycemia with glucose administration.
Initiate treatment for infections with appropriate antibiotics if indicated.
Monitoring and Follow-up:
Continuous monitoring for recurrent seizures or complications such as aspiration pneumonia.
Referral to neurology for further evaluation and management if new-onset seizures are diagnosed.
Challenges and Considerations
Seizures can be challenging due to their varied presentations and potential underlying causes. It is crucial to differentiate between acute symptomatic seizures and those indicative of epilepsy. Identifying red flags such as prolonged postictal confusion, focal neurological deficits, or signs of systemic illness can guide further investigation and management.
By taking a systematic approach to the assessment and management of seizures in the emergency setting, you can effectively address this condition while ensuring appropriate follow-up care.
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