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