Episode 82.0 – ED Management of Seizures

Jan 30, 2017

Delve into the intricacies of emergency management for seizures. Learn the vital distinctions between seizures and syncopal events, with essential interventions highlighted. Discover the first-line use of benzodiazepines for seizure termination. Explore the five categories of causes to ensure no potential issues are overlooked. For first-time seizures, a thorough evaluation is key, and follow-up with a neurologist is recommended. In cases of status epilepticus, aggressive benzodiazepine administration may pave the way for advanced treatments.

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ADVICE

Differentiate Seizure from Syncope

Differentiate seizure from syncope using history and exam, focusing on post-ictal state presence.
Always obtain a 12-lead EKG on first-time seizures to identify possible cardiac causes.

ADVICE

Benzodiazepines for Seizure Termination

Benzodiazepines are first-line for seizure termination, with IM midazolam or lorazepam if no IV access.
Typical doses: 10 mg midazolam IM or 2-4 mg lorazepam IM for rapid seizure control.

ADVICE

Systematic Seizure Cause Evaluation

Always evaluate seizures by considering vital sign abnormalities, CNS infections, toxic/metabolic issues, CNS lesions, and epilepsy.
This systematic approach helps avoid missing serious underlying causes.

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This week we discuss the ED management of seizures focusing on treatment and workup particularly of a 1st seizure episode.

Download Leave a Comment Tags: Neurology, Seizure, Status Epilepticus

Show Notes

Take Home Points

Get a detailed history to tease out whether the patient had a seizure or a syncopal event. Regardless, get an EKG on 1st time seizures in case it was actually syncope.
BZDs are first line therapy for seizure termination. If you don’t have IV access, go with 10 mg of midazolam or 2-4 mg of lorazepam IM
Always review the 5 main categories for causes of seizures in order to make sure you’re not missing anything. Those categories once again are vital sign abnormalities, CNS infections, toxic/metabolic issues, CNS space occupying lesions including masses and bleeds and finally epilepsy.
In patients with a first time seizure without a particular cause and return to baseline neurologic status, there’s unlikely to be any benefit to a NCHCT or to starting an AED. Scheduling close follow up with a neurologist is very reasonable. The key is to do a thorough examination and make sure you’re not missing a subtle abnormality.
Finally, in status epilepticus hit the patient with 2-3 hefty doses of BZDs and if the seizure is still ongoing, strongly consider moving to propofol and intubation in order to rapidly control the seizure activity.

Read More

Core EM: Parenteral Benzodiazepines

LITFL: Seizure

EMCrit: Podcast 155 – Status Epilepticus with Tom Bleck

First10EM: Management of Status Epilepticus in the Emergency Department

Huff SJ 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; 43(5): 605-25. PMID: 15111920