Here’s Dr. Chan with today’s Morning Report!
Unprovoked First Seizure in Adults
Was this really a seizure?
-Fair Marker: Incontinence (38% sensitive, 57% specific)
-Strong Markers: Postictal confusion, tongue biting, cyanosis, confirmed unresponsiveness, aura, eye deviation, rhythmic limb shaking, or dystonic posturing
-Seizure 5x more likely than syncope if patient disoriented after event and 3x more likely if the patient was aged < 45 years.
DDX:
(unknown) primary seizure disorder, psych disorder, syncope, trauma, ICH, brain mass, vascular lesion, migraine headache, hyperventilation syndrome, narcolepsy, infection, metabolic derangement (low or high sodium or glc, uremia, eclampsia (may occur up to 8 weeks post partum), toxins, drugs, ETOH or drug withdrawal, hypertensive encephalopathy, anoxic ischemia
PE:
ABCs, general exam + full neuro, detailed mental status (repeated if not at baseline), undress and look for trauma
Labs:
Fingerstick, electrolytes, pregnancy test, anti-epileptic levels, pregnancy test, drug screen.
-Pregnancy test + up to 3 weeks post partum.
-LP indicated it pt is febrile or immunocompromised or suspected SAH w/ – head CT
-EKG cheap simple test important for cardiogenic syncope and toxicities
-Prolactin (elevated for up to 60 minutes, not routinely ordered)
Tests:
-EEG (as inpatient or outpatient)
-Head CT- changes acute management in up to 17% of cases, in “alcohol related convulsion”, 4% had findings that changed clinical management (and hx and PE did not predict this).
Start Anti-epileptic drugs in ED?
-Clinicians should advise patients that immediate AED therapy, as compared with delay of treatment pending a second seizure, is likely to reduce the risk for a seizure recurrence in the two years subsequent to a first seizure (Level B). (57 percent by one year and 73 percent by four years),
– Clinicians should also advise such patients that clinical factors associated with an increased risk for seizure recurrence include a prior brain insult such as a stroke or trauma (Level A) and an EEG with epileptiform abnormalities (Level A).
Disposition:
If not in status, back to baseline, life-threatening conditions excluded- close neuro f/u and not cleared to drive until physician or state law clears
Sources:
Al-Mufti, F; Claassen, J (Oct 2014). “Neurocritical Care: Status Epilepticus Review.”. Critical Care Clinics 30 (4): 751–764.doi:10.1016/j.ccc.2014.06.006. PMID 25257739.
Brigo, Francesco, et al. “The Diagnostic Value of Urinary Incontinence in the Differential Diagnosis of Seizures.” Seizure 22.2 (2013): 85-90. Web.
Earnest MP, Feldman H, Marx JA, et al. Intracranial lesions shown by CT scans in 259 cases of first alcohol-related seizures. Neurology. 1988;38(10):1561-1565.
Haenel, A. F. “The Postpartum Course of the HCG Titer of Maternal Blood and Its Clinical Relevance.” Z Geburtshilfe Perinatol 190.6 (1986): 275-78. Web.
Sheldon R, Rose S, Ritchie D, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002;40(1):142-148.
Thijs RD, Wagenaar WA, Middelkoop HA, et al. Transient loss of consciousness through the eyes of a witness. Neurology. 2008;71(21):1713-1718.
Jay Khadpe MD
- Editor in Chief of "The Original Kings of County"
- Assistant Professor of Emergency Medicine
- Assistant Residency Director
- SUNY Downstate / Kings County Hospital
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1 Comment
iandesouza · November 29, 2015 at 6:27 pm
Nice post, Chan. This came up during a shift where a “stroke code” was called on a patient who had just had a seizure in the interest of “facilitating an emergent CT for possible hemorrhagic CVA”. Putting aside the issue of irresponsible resource utilization of activating stroke codes for patients that already have a contraindication to TPA (seizure), we further discussed the need to perform CT in first-time seizures and immediately went to this lovely post and had a real-time discussion with the writer herself.
This review cites current ACEP policy for seizures that is a consensus guideline (2014 American College of Emergency Physicians Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures):
“Immediate noncontrast CT is POSSIBLY useful to assess for structural lesion, especially when there is an abnormal neurological examination result, predisposing history, or focal onset of the seizures.” (Level B)
Furthermore, Harden et al, (Neurology 2007;69;1772) when reporting the “17% change in management rate” state:
“The list of specific abnormalities that were included as leading to a change in acute or
urgent management were as follows: traumatic brain injury including depressed skull fracture, subdural hematomas, nontraumatic bleeding including from arteriovenous malformations and other types of cerebral hemorrhages, cerebrovascular accidents, tumors, brain abscesses, cysticercosis, obstructive hydrocephalus and shunt malfunction,
Aicardi syndrome, Miller-Diecker syndrome, tuberous sclerosis, and CNS toxoplasmosis.”
This is a good reminder to fully and serially EXAMINE the patient before determining the need to perform CT. We should also consider the consequences of incidental findings and the radiation risk and in the younger patient. Based on the 2014 ACEP policy (and the limited-quality references cited in the guideline), we should not be performing CT in atraumatic, non-immunocompromised patients with first-time seizures who have recovered and have a normal neurologic exam.