Understanding Seizures and Status Epilepticus for Junior Doctors

Seizures and status epilepticus are common emergencies that junior doctors will encounter. A well-structured approach to history-taking, examination, investigations, and management is crucial to providing effective care. Let's break it down into manageable parts so that you can confidently assess and manage these patients.

·     History Taking in Seizures

When a patient presents after a seizure, obtaining a detailed history is essential, not only to confirm the diagnosis but also to identify the underlying cause. Key questions include:

·       Presenting Complaint:

·       What happened during the event?

·       Ask witnesses or the patient (if conscious) to describe the event. Was there loss of consciousness, limb jerking, or incontinence? This helps differentiate seizures from other causes of collapse (e.g., syncope, psychogenic non-epileptic seizures).

·       Was there an aura or warning sign?

·       Auras may include sensory disturbances, odd smells, or feelings of déjà vu. This can help localize the seizure origin in the brain.

·       Before the Seizure:

·       Was there a known trigger?

·       Triggers like sleep deprivation, alcohol, fever, or stress can precipitate seizures.

·       Any previous seizures or epilepsy diagnosis?

·       If the patient is known to have epilepsy, find out if this seizure was typical for them or if there are new features.

·       Recent head injury or infection?

·       Head trauma or central nervous system infections can precipitate seizures, particularly in those without a known seizure disorder.

·       During the Seizure:

·       What did the seizure look like?

·       Was there tonic (stiffening) or clonic (jerking) activity? Did the patient bite their tongue? Was there incontinence? These details are crucial in distinguishing between seizure types (e.g., focal vs. generalized).

·       After the Seizure:

·       Post-ictal state (confusion, drowsiness)?

o   Ask how long it took for the patient to return to normal. A prolonged post-ictal period can indicate a more serious seizure disorder, such as status epilepticus.

·       Any injuries from the seizure?

o   Look for trauma that may have occurred during the seizure, like head injuries or fractures.

·       Examination Findings

A thorough examination can provide important clues about the cause and consequences of a seizure.

·       General Examination:

·       Vital signs: Hypoxia, fever, and hypertension can all be triggers or complications of seizures.

·       Injuries: Look for trauma, especially head injuries or tongue lacerations.

·       Neurological Examination:

·       Level of consciousness: Prolonged altered consciousness post-seizure may indicate non-convulsive status epilepticus.

·       Focal neurological deficits: Weakness, visual field defects, or cranial nerve palsies could suggest a focal seizure, stroke, or brain lesion.

·       Systemic Examination:

·       Cardiovascular and respiratory systems: Identify any signs of arrhythmias, heart failure, or respiratory distress, as these may complicate or cause seizures.

·       Investigations in Seizures

While history and examination will guide your approach, investigations are vital for identifying the underlying cause.

·       Bedside Investigations:

·       Blood glucose: Hypoglycemia is a reversible cause of seizures that must be checked immediately.

·       ECG: Consider if the patient had a syncopal episode rather than a seizure; ECG can rule out arrhythmias.

·       Laboratory Tests:

·       Electrolytes (U&Es): Sodium, calcium, and magnesium imbalances can trigger seizures.

·       Infection markers: Consider septic screens (blood cultures, lumbar puncture) if infection is suspected.

·       Toxicology screen: Consider if drugs, alcohol, or toxins may have triggered the seizure.

·       Antiepileptic drug levels: If the patient is known to have epilepsy, check if they are subtherapeutic.

·       Imaging:

·       CT head: For new-onset seizures, particularly in patients with trauma or neurological deficits, a CT head scan is vital to rule out bleeds or masses.

·       MRI brain: More detailed imaging is required for non-urgent cases or if structural abnormalities are suspected (e.g., tumors, malformations).

·       EEG (Electroencephalogram):

·       In cases of uncertainty or ongoing abnormal brain activity (especially in status epilepticus), an EEG can help confirm a diagnosis and guide management.

·       Management of Seizures and Status Epilepticus

·       Acute Seizure Management:

·       Protect the airway: Ensure the patient is in a safe position to prevent aspiration (e.g., recovery position). Consider intubation if there is airway compromise.

·       Time the seizure: Most seizures resolve within 5 minutes. If it exceeds this, it may become status epilepticus (more on this below).

·       Terminate the seizure: If the seizure persists beyond 5 minutes or there is a cluster of seizures, pharmacological intervention is required:

·       First-line: IV benzodiazepines (e.g., lorazepam 4 mg or diazepam 10 mg).

·       Second-line: IV phenytoin or levetiracetam if benzodiazepines fail.

·       Management of Status :

·       Definition: Status epilepticus is a seizure lasting more than 5 minutes or recurrent seizures without full recovery between episodes.

·       ABC Approach:

·       Airway: Secure airway early if the patient is not protecting it.

·       Breathing: Administer high-flow oxygen.

·       Circulation: Secure IV access and administer fluids.

·       Escalation:

·       1st-line (5-20 minutes): IV lorazepam. If IV access is delayed, consider IM midazolam.

·       2nd-line (20-40 minutes): If seizures persist, give IV phenytoin or IV levetiracetam.

·       Refractory status epilepticus (>40 minutes): Consider general anesthesia with propofol or thiopental if seizures are still not controlled.

·       Address Underlying Cause:

·       Treat the underlying cause (e.g., hypoglycemia, infection, electrolyte disturbance) alongside seizure termination.

·       Post-Seizure Care:

·       Observation: Patients should be monitored post-seizure for complications like aspiration, rhabdomyolysis, or worsening neurological deficits.

·       Referral to Neurology: For patients with new-onset seizures or poorly controlled epilepsy, early neurology input is essential.