1.04 Seizures (Convulsions, fits)
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agk's Library of Common Simple Emergencies

Presentation
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The patient may be found in the street, the 
hospital, or the emergency room. The patient 
may complain of an "aura," feel he is "about to 
have a seizure," experience a brief petit mal 
"absence," exhibit the repetitive stereotypical 
behavior of continuous partial seizures, the 
whole-body tonic stiffness or clonic jerking of 
grand mal seizures, or simply be found in the 
gradual recovery of the postictal phase. 
Patients experiencing grand mal seizures can 
injure themselves, and generalized seizures 
prolonged for more than a couple of minutes can 
lead to hypoxia, acidosis, and even brain 
damage.

What to do:
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- If the patient is having a grand mal seizure, 
   stand by him for a few minutes until his 
   thrashing subsides, to guard against injury 
   or airway obstruction. Usually only suction- 
   ing or turning the patient on his side is 
   required, but breathing will be uncoordinat- 
   ed until the tonic-clonic phase is over.
- Watch the pattern of the seizure for clues to 
   the etiology. (Did clonus start in one place 
   and "march" out to the rest of the body? Did 
   the eyes deviate one way throughout the 
   seizure? Did the whole body participate?)
- If the seizure lasts more than two minutes, 
   or recurs before the patient regains 
   consciousness, it has overwhelmed the 
   brain's natural buffers and may require 
   drugs to stop. This is defined as status 
   epilepticus, and is best treated with 
   diazepam (Valium) 5-l0mg iv, followed by 
   gradual loading with iv phenytoin.
- Check a quick finger stick blood sugar 
   (especially if the patient is wearing a 
   "diabetes" MedicAlert bracelet or medallion) 
   and administer intravenous glucose if it is 
   below normal.
- If the patient arrives postictal, examine him 
   thoroughly for injuries and record a 
   complete neurological examination (the 
   results of which are apt to be bizarre). 
   Repeat the neurological exam periodically. 
   If the patient is indeed recovering, you may 
   be able to obviate much of the diagnostic 
   workup by waiting until he is lucid enough 
   to give a history.
- If the patient arrives awake and oriented 
   following an alleged seizure, corroborate 
   the history through witnesses or the 
   presence of injuries like a scalp laceration 
   or a bitten tongue. Doubt a grand mal 
   seizure without a prolonged postictal 
   recovery period.
- If the patient has a previous history of 
   seizure disorder, or is taking anti- 
   convulsant medications, check old records, 
   speak to his physician, find out whether he 
   has been worked up for an etiology, look for 
   reasons for this relapse (e.g., infection, 
   ethanol, lack of sleep), and draw blood for 
   levels of anticonvulsants.
- If the seizure is clearly related to alcohol 
   withdrawal, ascertain why the patient 
   reduced his consumption. He might be broke, 
   be suffering from pancreatitis or gastritis 
   that requires further evaluation and 
   treatment, or have decided to dry out 
   completely. If the last, and is demonstr- 
   ating signs of delerium tremens, such as 
   tremors, tachycardia and hallucinations, his 
   withdrawal should be medically supervised, 
   and covered with benzodiazepines (e.g. 
   Librium, Valium, Ativan). Many emergency 
   physicians presumptively treat alcohol 
   withdrawal symptoms with an intravenous 
   infusion containing glucose, l00mg thiamine, 
   2Gm magnesium and multivitamins.
- If the seizure is a new event, make arrange- 
   ments for a workup, including an EEG. About 
   half of patients with a new onset of 
   seizures will require hospitalization. Most 
   of these patients can be identified by 
   abnormalities on physical examination, head 
   CT or blood counts. Other tests (lumbar 
   puncture, serum electrolytes, glucose, 
   calcium) may also identify new seizure 
   victims who require admission.
- If the workup will be as an outpatient, the 
   patient should be loaded with phenytoin 
   (Dilantin) 17-20mg/kg over 1/2 hour iv, or 
   over 6 hours po to protect him from further 
   seizures. If there is any question, check a 
   serum phenytoin level before giving this 
   loading dose. Patients should be on a 
   cardiac monitor during iv loading, which 
   should be slowed if they develop conduction 
   blocks or dysrythmias.

What not to do:
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- Do not stick anything in the mouth of a 
   seizing patient. The ubiquitous padded 
   throat sticks may be nice for a patient to 
   hold and bite on at the first sign of a 
   seizure, but do nothing to protect his 
   airway, and are ineffective when the jaw is 
   clenched.
- Do not rush to give intravenous diazepam to a 
   seizing patient. Most seizures stop in a few 
   minutes. It is diagnostically useful to see 
   how the seizure resolves on its own; also, 
   the patient will awaken sooner if he has not 
   been medicated. Reserve diazepam for genuine 
   status epilepticus.
- Be careful not to assume an alcoholic 
   etiology. Ethanol abusers sustain more head 
   trauma and seizure disorders than the 
   population at large.
- Do not treat alcohol withdrawal seizures with 
   phenobarbital or phenytoin. Both lack 
   efficacy (and necessity, since the problem 
   is self-limiting) and can themselves produce 
   withdrawal seizures.
- Do not rule out alcohol withdrawal seizures 
   on the basis of a toxic serum ethanol level. 
   The patient may actually be withdrawing from 
   a yet higher baseline.
- Do not be fooled by pseudoseizures. Even 
   patients with genuine epilepsy occasionally 
   fake seizures for various reasons, and an 
   exceptional performer can be convincing. 
   Amateurs may be roused with ammonia or 
   smelling salts, but few can simulate the 
   fluctuating neurological abnormalities of 
   the postictal state, and probably no one can 
   produce the pronounced metabolic acidosis or 
   serum lactate elevation of a grand mal 
   seizure.
- Do not release a patient with persistent 
   neurologic abnormalities without a head CT 
   or specialty consultation.
- Do not let a seizure victim drive home.

Discussion
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Grand mal seizures are frightening, and inspire 
observers to "do something," but usually all 
that is necessary is to stand by and prevent 
the patient from injuring himself. The age of 
the patient makes some difference as to the 
probable underlying etiology of a first seizure 
and therefore makes some difference in 
disposition. 
- Under age 3, rapid rise of temperature can 
   cause a generalized febrile seizure which 
   does not lead to epilepsy, and is best 
   treated by control of fever. Brief febrile 
   seizures may not require a lumbar puncture 
   to evaluate the cause of the fever, but 
   these children should be managed in 
   consultation with the primary care physician 
   to ensure early follow up.
- In the 12 to 20-year-old patient, the seizure 
   is probably "idiopathic," although other 
   causes are certainly possible.
- In the 40-year-old patient with a first 
   seizure, one needs to exclude neoplasm, 
   post-traumatic epilepsy, or withdrawal.
- In the 65-year-old patient with a first 
   seizure, cerebrovascular insufficiency must 
   also be considered. Such a patient should be 
   treated and worked up with the possibility 
   of an impending stroke, in addition to the 
   other possible causes.

For these reasons, a patient with a first 
seizure who is 30 years old or older needs to 
have a CT scan, preferably while in the ED. A 
noncontrast study can be obtained initially. If 
there are abnormalities present or if there are 
still suspicions of a focal abnormality, a 
contrast study can be obtained at the same time 
or later, whichever is convenient. Also, 
patients should be discharged for outpatient 
care only if there is full recovery of 
neurological function, with a full loading dose 
of phenytoin, and with clear arrangements for 
follow-up or return to the ED if another 
seizure occurs. An EEG can usually be done 
electively, except in status epilepticus. A 
toxic screen may be needed to detect the many 
overdoses that can present as seizures, 
including amphetamines, cocaine, isoniazide, 
lidocaine, lithium, phencyclidine, phenytoin 
and tricyclic antidepressants.

References:
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- Eisner RF, Turnbull TL, Howes DS et al: 
   Efficacy of a "standard" seizure workup in 
   the emergency department. *Ann Emerg Med* 
   1986;15:33-39.
- Henneman PL, DeRoos F, Lewis RJ: Determining 
   the need for admission in patients with 
   new-onset seizures. *Ann Emerg Med* 1994; 
   24:1108-1114.

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