Seizure in Adults
by Dr. Jason Van Valkenburg
Emergency Medicine/Internal Medicine Combined Conference August 22, 2013
2-5% of people have at least 1 non-febrile seizure during their lifetime
1% of US population with epilepsy — 28% require treatment in ED’s annually
Syncope vs seizure — history (e.g. amnesia, tongue-biting, incontinence, etc.) is critical to try to determine if cause of presentation is syncope or seizure, but even with history this can often be difficult
Epilepsy — < 50% of cases have an identifiable cause
With age, certain causes become more common, e.g. tumor, CVA
Evaluation:
Turnbull et al: Laboratory evaluation: 8% of 136 patients had correctable lab abnormalities, only 2 were unexpected
Glucose is the most common abnormality
ACEP Clinical Practice Guidelines: For an otherwise healthy adult with new onset seizure who has returned to baseline neuro status — check glucose and sodium, pregnancy test if female of child-bearing age, LP if immunocompromised
Neuroimaging:
Indications and timing remain controversial
Henneman et al in retrospective review noted 22% of patients with first time seizure and normal neuro exam had abnormal noncontrast head CT results
Earnest et al evaluated 250 patients with suspected alcohol withdrawal seizures:
58% had an abnormal CT
6% had a clinically significant lesion
7 of the 16 with a clinically significant lesion had a normal neuro exam and no sign of trauma
ACEP: In an adult with a new onset seizure who has returned to baseline neuro status, imaging is recommended, but if desired, it may be deferred if patient has reliable followup.
Admission and initiation of anti-epileptic medication: No good evidence to support any strong recommendations or guidelines
Very individualized
ACEP: normal neuro exam with no significant co-morbidities can be discharged with outpatient followup — these patients do not need admission or anti-epileptics
Risk of seizure recurrence is quite variable: around 15% risk of recurrence
When to get EEG:
Outpatient setting: Predictive of seizure recurrence and allows categorization and optimization of treatment
ED and Inpatient: If any concern for status or prolonged altered mental status with delay in return to baseline
Treiman et al: 518 status epilepticus patients: 25% had EEG evidence of ongoing continued seizure activity even though bedside assessment suggested that seizure had terminated
EM Practice Guideline 2010:
EEG monitoring is indicated to rule out nonconvulsive status epilepticus in patients receiving aggressive anti-epileptic therapy
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