Seizure (New onset seizures)

  1. Provoked vs unprovoked

  • Provoked/reversible? (metabolic derangement, intoxication/withdrawal, infection, hypoxia, or acute stroke/ICH/TBI.)

  • Unprovoked/Not reversible immediately? (no immediate trigger, underlying seizure tendency such as epilepsy, remote stroke scar, tumor, prior TBI, or cortical lesion)

  1. Status epilepticus?

  • Convulsive seizure lasting ≥5 minute or 2+ seizures without recovery of consciousness

  1. type?

  • Generalized seizure (both hemispheres)

    • Tonic-clonic: stiffening + rhythmic jerking + postictal state

    • Absence: brief staring, seconds, quick recovery

    • Myoclonic: brief shock-like jerks

    • Tonic: stiffening only

    • Clonic: rhythmic jerking only

    • Atonic: sudden loss of tone / drop attack

  • Focal seizure (starts in one brain area)

    • Focal aware: awareness preserved; jerking/numbness/deja vu/odd smell

    • Focal impaired awareness: confusion, staring, automatisms (lip smacking, picking)

D: Mins -- X-- Witnessed by ---
CC: stiffening + rhythmic jerking + head/eye deviation + postictal state OR automatisms (lip smacking, picking)
Onset/Progression: ((s/g-c/i-w/i/u))
PP: NO OTHER
PN: fever, meningismus, trauma, focal Sx, persistent AMS, drug usel, chest pain, palpitations.
mHx: new meds (bupropion/tramadol), epilepsy.
sHx: substance use
Initial DATA: CBC, CMP, tox/EtOH, CK (if rabdo), AED levels (phenytoin, valproic acid, carbamazepine and phenobarbital ), CTH
COURSE:
////
MEDS:
DDX: Syncopal Convulsions; hyperventilation syndrome; movement disorder; tremor; psychogenic nonepileptic seizure, narcolepsy.

Plan:
-- Neurology consulted, NSG ( if mass)

  • MRI with contrast for first seizure

  • EEG within 24-48 hours if not seizing (discuss with neurology)
    -- trending labs daily , replete as needed
    -- PT/OT for eval
    -- Continuous telemetry
    -- seizure precautions (padded bedrails prevent injury during seizure)
    -- if active seizure O2 by face mask, position patient on side, suction airway if needed (do not try to restrain)
    -- make sure protecting airway if not call RRT
    -- If seizure lasts >2–3 min, abort immediately: Lorazepam 4 mg IV or Midazolam 5 mg IV at 0 min, repeat at 5 min if still seizing; if no IV access, give Midazolam 10 mg IM once. (call neuro) , If ongoing by 10 min, load Levetiracetam (Keppra) 40–60 mg/kg (max 4.5 g) and call Neurology early. Persistent seizures require ICU, continuous Midazolam drip, and likely intubation for airway protection, GCS <8, or Propofol infusion.

-- for new first-time seizures who have returned to baseline, discuss with neurology would be reasonable to perform EEG in the outpatient setting if there is not a clear reason
-- consider LP and BCx if (immunocompromised, febrile, not returning to baseline or no other etiology identified)
-- discuss with attending reporting to Department of Public Health They will report this to the DMV, No driving until event-free for 6 months (state dependent)

Note:
-- provoked vs unprovoked
-- >5 minutes → status epilepticus
-- Focal features: one limb jerking, head/eye deviation, speech arrest, automatisms (lip smacking, picking), asymmetric movements.
-- Generalized features: sudden loss of consciousness, symmetric tonic–clonic movements, cry out, tongue biting (especially lateral), incontinence
-- normal EEG does not rule-out epilepsy,EEG most sensitive if performed <24 hours after seizure we can see interictal (between seizures) epileptiform discharges, even if no seizure occurs
-- MRI with contrast for first seizure, focal neuro exam, h/o trauma, malignancy, HIV
-- If patient has a known seizure disorder with a reversible underlying triggerand has returned to their baseline neurologic exam, EEG may not be necessary
-- In patients with new first-time seizures who have returned to baseline, would be reasonable to perform EEG in the outpatient setting if there is not a clear reason

Look for injuries sustained while seizing: . Assess level of consciousness and do a full neuro exam, looking in particular for any focal neurological deficits that could guide your workup. Focal neurological deficits may indicate an underlying brain lesion, or they may reflect post-ictal (“Todd’s”) paralysis, which should resolve within 48 hours (can be longer for elderly patients, especially if several sedating medications are administered). Persistent encephalopathy may reflect recurrent seizures or status epilepticus