Rosen & Barkin's 5-Minute Emergency Medicine Consult (639 page)

• Patients with status epilepticus should be admitted to the ICU
  
• Patients with seizures secondary to underlying disease (e.g., meningitis, intracranial lesion) must be admitted for appropriate treatment and monitoring
  
• Patients with poorly controlled repetitive seizures should be admitted for monitoring
  
• Delirium tremens
  

• Patient with normal workup and appropriate neurology follow-up
  
• Uncomplicated seizure in patient with chronic seizure disorder
  
• Seizure secondary to reversible cause:
  
  • Hypoglycemia if blood sugar has stabilized
    
  • Alcohol withdrawal if baseline mental status and no further seizures
    
• Simple febrile seizure
  

• Consider early neurology follow-up
  
• Anticonvulsant drug level monitoring
  

No driving until seizures are under control

• Most common cause of recurrent seizure is subtherapeutic anticonvulsant drug level
  
• Benzodiazepines are the 1st-line treatment to stop seizure activity
  
• Treat the underlying cause if identifiable
  
• Seizures lasting longer than 5–10 min should be treated as status epilepticus
  
• Valproate likely works as well as phenytoin/fosphenytoin as a second line agent in treating status epilepticus and can be administered more quickly with less chance of an adverse effect
  

• ACEP Clinical Policies Subcommittee (Writing Committee) on Seizures; Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures.
  Ann Emerg Med.
  2014;63:437--447.
  
• French JA, Pedley TA. Clinical practice. Initial management of epilepsy.
  N Engl J Med
  . 2008;359:166–176.
  
• Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure.
  Emerg Med Clin North Am.
  2011;29:41–49.
  
• Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
  Neurology.
  2007;69:1996–2007.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Headaches
  
• Hypertensive Emergencies
  
• Intracerebral Hemorrhage
  
• Preeclampsia/Eclampsia
  
• Seizure, Febrile
  
• Seizure, Pediatric
  

CODES

• 345.00 Generalized nonconvulsive epilepsy, without mention of intractable epilepsy
  
• 345.90 Epilepsy, unspecified, without mention of intractable epilepsy
  
• 780.39 Other convulsions
  

BASICS

• Occurs between 6 mo and 5 yr of age associated with fever:
  
  • No evidence of intracranial infection or other defined CNS primary cause
    
  • Average age of onset is 18–22 mo
    
  • Children with previous nonfebrile seizures excluded
    
• Most common pediatric convulsive disorder:
  
  • Affects 2–4% of young children in US
    
• Occurs in normal children with a systemic viral illness
  
• High-risk children:
  
  • History of febrile seizure in immediate family members
    
  • Delayed neurologic development
    
  • Males
    
• Subgroups:
  
  • Simple febrile seizures:
    
    • Brief, self-limited lasting <10–15 min, resolve spontaneously
      
    • Generalized without any focal features
      
  • Complex febrile seizures:
    
    • Duration >15 min
      
    • Focal features
      
    • More than 1 seizure within a 24-hr period
      
• Risk of recurrence:
  
  • One-third of cases
    
  • Early age of onset, history of febrile or afebrile seizures in 1st-degree relatives, and temperature <40°C during initial seizure increase the likelihood of recurrence
    
• Risk of subsequent epilepsy:
  
  • Greatest for those with prior abnormal neurologic development, a complex (>15 min) 1st febrile seizure, a focal seizure, or a family history of afebrile seizures
    
  • Only slightly greater than the general population if 1st febrile seizure is simple and neurologic development normal
    
  • Not affected by the use of prophylactic medications
    

Common childhood infections:

• Upper respiratory illnesses
  
• Otitis media
  
• Roseola
  
• GI infections
  
• Shigella
  gastroenteritis
  

DIAGNOSIS

• Fever
  
• Seizure may occur concurrent with recognition of the febrile illness
  
• Seizure
  
• Generalized tonic–clonic seizure most common:
  
  • Tonic phase:
    
    • Muscular rigidity
      
    • Apnea and incontinence
      
    • Self-limited and last only a few minutes
      
  • Other seizure types:
    
    • Staring with stiffness
      
    • Limpness
      
    • Jerking movements without prior stiffening
      

• Careful history and physical exam help confirm diagnosis and rule out other etiologies
  
• Symptoms/evidence of infectious illness
  
• Duration and pattern of fever
  
• Medication exposure/toxin
  
• Recent immunizations
  
• Trauma/occult trauma
  
• Growth pattern and developmental level
  
• Family history of seizures
  
• Complete description of seizure
  

• Reducing temperature may be useful in evaluation; give antipyretics early
  
• Evidence of infectious illness-rash, ear infection, respiratory infection, diarrhea, etc.
  
• Careful neurologic exam including mental status
  
• Presence of meningismus, bulging fontanelle, nuchal rigidity, etc.
  
• Evidence of focal deficit or increased ICP
  

• Routine lab studies not indicated
  
• Evaluate for a source of fever if serious bacterial infection is suspected:
  
  • WBC
    
  • UA
    
  • Blood and urine cultures
    
• Lumbar puncture:
  
  • Not routinely indicated
    
  • Indications 12–18 mo of age:
    
    • History or irritability, decreased feeding, lethargy
      
    • Consider if deficient in
      Haemophilus influenzae
      type b or
      Streptococcus pneumoniae
      immunizations
      
    • Physical signs of meningitis and/or history consistent with meningitis
      
    • Complex seizure
      
    • Prolonged postictal state
      
    • Prior antibiotics altering presentation
      
    • Abnormal mentation after postictal state
      
  • Indications >18 mo old:
    
    • Signs/symptoms of CNS infection present
      
    • Electrolytes and bedside glucose in infants and children with vomiting or diarrhea
      
• EEG:
  
  • Not helpful in the initial evaluation of febrile seizures
    
  • May be indicated if developmental delay, underlying neurologic abnormality, or focal seizure
    
  • Does not help predict recurrences or risk for later epilepsy
    
• Anticonvulsant levels
  
• Toxicology studies of blood and urine if history and physical exam suggestive
  

• Chest radiograph only in patients with significant respiratory symptoms or pertinent findings on physical exam
  
• Head CT:
  
  • Indicated with traumatic injuries, focal neurologic findings, or inability to exclude elevated intracranial pressure
    

• Febrile delirium
  
• Febrile shivering with pallor and perioral cyanosis
  
• Breath-holding spell during febrile event
  
• Acute life-threatening event
  
• Other causes of seizure:
  
  • Afebrile seizure occurring during febrile event
    
  • Sudden discontinuance of anticonvulsants
    
  • Infection:
    
    • Meningitis/encephalitis
      
    • Acute gastroenteritis, often with dehydration
      
  • Head trauma
    
  • Toxicologic:
    
    • Anticholinergics
      
    • Sympathomimetics
      
    • Other
      
  • Hypoxia
    
  • Metabolic disease
    
  • Intracranial masses
    
  • CNS vascular lesions