Seizure

Differential Diagnosis

Epilepsy or other primary seizure disorder
Drugs:
- Withdrawal syndromes (e.g. alcohol)
- Drug overdoses
- Illicit drugs (cocaine)
- Local anesthetic toxicity
Infection:
- Meningitis
- Encephalitis
- Sepsis
Metabolic:
- Hypoglycemia
- Hypoxemia/hypercarbia
- Hyponatremia/hypocalcemia/hypomagnesemia
- Toxins (uremic, hepatic encephalopathy)
- Dialysis disequilibrium syndrome
- Porphyria
Structural:
- Ischemic or hemorrhagic stroke
- Intracranial tumor
- Cerebral edema
Pregnancy:
- Eclamptic seizure
- Amniotic fluid embolism

Management

Inform surgical team & call for help
Supplemental oxygen, monitors, establish IV access
If needed, hand ventilate with 100% O2 - DO NOT hyperventilate (↓ seizure threshold)
Focused cardiorespiratory & neurological exams
Rapid glucometer
Bloodwork: CBC, electrolytes, extended electrolytes, blood glucose, liver enzymes, kidney function tests, ABG
Give anticonvulsants if seizure > 2min:
- Benzodiazepines = 1st line
  - Midazolam 0.05mg/kg or 1mg at a time, titrate to effect
  - Diazepam 0.1-0.4mg/kg IV, 0.04-0.2 mg/kg PR
  - Lorazepam 1-2 mg at a time, titrate to effect
- Propofol 0.5mg/kg at a time, titrate to effect
- Phenytoin 20mg/kg total loading dose at a rate of 50mg/min, watch for hypotension & arrhythmias
- Barbiturates:
  - Phenobarbital 20 mg/kg infused at a rate of 50 mg/minute
  - Thiopental 25-100mg dose
  - Pentobarbital 10 mg/kg infused at a rate of up to 100 mg/minute
- Valproic acid IV 30mg/kg over 15 min
Consult neurology for further diagnosis & management
If ↑ ICP: institute treatment (mannitol, furosemide, hypertonic saline, mild hyperventilation, elevate HOB, etc)
If eclampsia: MgSO4 4g IV bolus over 15 min, then 1-2g/hr
If no resolution & respiratory compromise:
- Paralyze & intubate
- Succinylcholine IM (4mg/kg) for intubation if no IV access