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1.04 Seizures (Convulsions, fits)


Presentation

The patient may be found in the street, the hospital, or the emergency room. The patient may complain of an "aura," feel he is "about to have a seizure," experience a brief petit mal "absence," exhibit the repetitive stereotypical behavior of continuous partial seizures, the whole-body tonic stiffness or clonic jerking of grand mal seizures, or simply be found in the gradual recovery of the postictal phase. Patients experiencing grand mal seizures can injure themselves, and generalized seizures prolonged for more than a couple of minutes can lead to hypoxia, acidosis, and even brain damage.

What to do:

What not to do:

Discussion

Grand mal seizures are frightening, and inspire observers to "do something," but usually all that is necessary is to stand by and prevent the patient from injuring himself. The age of the patient makes some difference as to the probable underlying etiology of a first seizure and therefore makes some difference in disposition. Under age 3, rapid rise of temperature can cause a generalized febrile seizure which does not lead to epilepsy, and is best treated by control of fever. Brief febrile seizures may not require a lumbar puncture to evaluate the cause of the fever, but these children should be managed in consultation with the primary care physician to ensure early follow up. In the 12 to 20-year-old patient, the seizure is probably "idio- pathic," although other causes are certainly possible. In the 40-year-old patient with a first seizure, one needs to exclude neoplasm, post-traumatic epilepsy, or withdrawal. In the 65-year-old patient with a first seizure, cerebrovascular insufficiency must also be considered. Such a patient should be treated and worked up with the possibility of an impending stroke, in addition to the other possible causes. For these reasons, a patient with a first seizure who is 30 years old or older needs to have a CT scan, preferably while in the ED. A noncontrast study can be obtained initially. If there are abnormalities present or if there are still suspicions of a focal abnormality, a contrast study can be obtained at the same time or later, whichever is convenient. Also, patients should be discharged for outpatient care, only if there is full recovery of neurological function, with a full loading dose of phenytoin, and with clear arrangements for follow-up or return to the ED if another seizure occurs. An EEG can usually be done electively, except in status epilepticus. A toxic screen may be needed to detect the many overdoses that can present as seizures, including amphetamines, cocaine, isoniazide, lidocaine, lithium, phencyclidine, phenytoin and tricyclic antidepressants.

References:


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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD