Seizure

SEIZURE
seizure
• Seizures are episodes of abnormal neuronal excitation and are
generally a manifestation of an underlying process.
• Epilepsy is a clinical condition in which an individual is subject to

recurrent seizures. It implies a fixed, excitatory condition of the brain
with a lower seizure threshold.
• status epilepticus is seizure activity ≥5 minutes, or two or more

seizures without regaining consciousness between seizures1
• refractory status epilepticus is persistent seizure activity despite the IV

administration of adequate amounts of two antiepileptic agents
PATHOPHYSIOLOGY
• Seizures occur when the abnormal, increased electrical activity of
initiating neurons activates adjacent neurons and propagates
-Seizuresare typically self-limited; at some
point the hyperpolarization subsides and
the bursts of electrical discharges from
the focus terminate. This cessation may
be related to reflex inhibition, neuronal
exhaustion, or alteration of the local
balance of neurotransmitters between the
excitatory acetylcholine and the inhibitory
γ-aminobutyric acid (GABA).
• Seizures are classified based on cause (primary or secondary), effect
on mentation, and motor activity
• Primary seizures are unprovoked and not linked to an inciting event.

Secondary seizures may be caused by trauma, illness, intoxications
and poisonings, metabolic disturbances, and cerebral tumors.
• The International League Against Epilepsy recommends dividing

seizures into two major groups: generalized seizures and partial
seizures
• When there are inadequate data to categorize the seizure, the seizure
is considered unclassified.
GTCS
The patient suddenly becomes rigid (tonic phase), trunk and extremities are
extended, and the patient falls to the ground.
As the tonic phase subsides, there are increasing coarse movements that
evolve into a symmetric, rhythmic (clonic) jerking of the trunk and
extremities.
Patients are often apneic during this period and may be cyanotic.
They often urinate and may vomit.
As the attack ends, the patient is left flaccid and unconscious, often with
deep, rapid breathing.
Typical attacks last from 60 to 90 seconds. Consciousness returns gradually.
Postictal confusion, myalgias, and fatigue may persist for several hours
Absence Seizure
• Absence seizures generally lasts for only a few seconds.
• Patient Appears to be in Altered conscious state ,confused
or detached, and current activity ceases but no change in
postural tone and no postictal symptoms.
• They may stare or have twitching of the eyelids. They may
not respond to voice or to other stimulation, exhibit
voluntary movements, or lose continence
• . Classic absence seizures occur in school-aged children. The
attacks can occur as frequently as 100 or more times daily.
They usually resolve as the child matures
• Similar attacks in adults are more likely to be minor complex
partial seizures and should not be termed absence
Focal Seizure Focal seizures are more likely to be secondary to a localized structural
lesion of the brain.
Focal seizures may spread to involve both hemispheres, mimicking a

typical generalized seizure, so the correct diagnosis may depend entirely
on demonstration of the focal discharge on an EEG recording
In simple partial focal seizures, the seizure remains localized, and

consciousness is not affected
Complex partial seizures are focal seizures in which consciousness or

mentation is affected. They are often caused by a focal discharge
originating in the temporal lobe and are sometimes referred to as
temporal lobe seizures
Complex partial seizures are commonly misdiagnosed as psychiatric problems d/t its symptoms including
automatism, visceral symptoms, hallucinations, memory disturbances, distorted perception, and affective
disorders
DIAGNOSIS
• Abrupt onset and termination, Most seizures last only 1 or 2 minutes,
unless the patient is in status epilepticus.
• Lack of recall. Except for simple partial seizures, patients usually cannot
recall the details of attack
• Most seizures are followed by a period of postictal confusion and lethargy
• Pseudoseizures can be difficult to distinguish from true seizures and may

occur in a patient who also has a documented seizure disorder.
Pseudoseizures are psychogenic in origin and are often associated with a
conversion disorder, panic disorder, psychosis
• There is usually no postictal confusion. Accurate diagnosis of
pseudoseizures may require prolonged EEG or video monitoring.
• In first onset seizure or unclear seizure history, more extensive studies

are usually needed and depend on the clinical context. Obtain serum
glucose, basic metabolic panel, lactate, calcium, magnesium,
toxicology studies.
• A seizure may result in a lactate-driven, wide anion gap metabolic

acidosis.2 Most lactate abnormalities will clear within 30 minutes. The
prolactin level may also be elevated for a brief period (15 to 60
minutes) immediately after a seizure
• CT scan of the head in the ED for patients with a first-ever seizure or
a change in established seizure patterns to evaluate for a structural
lesion may be taken. A noncontrast CT is an appropriate screening
tool.
• LP Study is indicated if the patient is febrile or immunocompromised
or if SAH is suspected and if the NCCT is normal.
TREATMENT
• The ideal initial antiepileptic regimen is a single-drug therapy that
controls seizures with minimum toxicity
• Management simultaneously focusing on identifying the reversible

causes, such as hypoxia and hypoglycemia, and initiating pharmacologic
treatment.
• Antiepileptic agents, such as valproate, lamotrigine, topiramate,

levetiracetam, and oxcarbazepine, are options for adults with new-
onset seizures
In actively seizing patients, ensuring central nervous system (CNS) perfusion and oxygenation is the
priority.
Oropharyngeal airways are contraindicated because they may induce gagging and vomiting and may
damage the teeth or tongue.
Oxygen may be administered to supplement immediate oxygenation and in preparation for possible rapid
sequence intubation. Suction should be made available.
• Lorazepam is the first-line treatment unless there is no vascular
access, in which case we recommend midazolam IM.
• If the patient continues to seize despite initial therapy with

lorazepam, second-line medications should be given
• If seizures continue, an additional half-loading dose of phenytoin,
fosphenytoin, or valproic acid can be given.
• If seizure activity continues, a careful reassessment should be done to

identify reversible underlying processes, such as bleeding, drug
overdose, and metabolic abnormalities that could have been missed
until this point.
• Preparations for endotracheal intubation and administration of third –

line therapies are indicated
- Patients in status epilepticus should be admitted to the intensive care unit and have
continuous electroencephalographic monitoring, which will be key to titrating the
dosage of sedation for seizure term
- If seizure activity continues, a careful reassessment should be done to identify

reversible underlying processes, such as bleeding, drug overdose, and metabolic
abnormalities that could have been missed until this point
• Administer glucose IV if hypoglycemia present.
• Monitor temperature continuously, and treat hyperthermia with
passive cooling.
• Place a urinary catheter to monitor urine output and insert a
nasogastric tube to help prevent aspiration.
• If toxic ingestion is suspected as the cause of seizures, proceed with GI
decontamination.
• Do not attempt lumbar puncture during status epilepticus. If bacterial
meningitis or encephalitis is suspected clinically, then immediately
start empiric antibiotic or antiviral therapy.
• Radiographic studies, such as a CT scan, will usually need to be
delayed until seizures are controlled
 THANK YOU

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SEIZURE

• Epilepsy is a clinical condition in which an individual is subject to

• status epilepticus is seizure activity ≥5 minutes, or two or more

• refractory status epilepticus is persistent seizure activity despite the IV

• Primary seizures are unprovoked and not linked to an inciting event.

• The International League Against Epilepsy recommends dividing

They often urinate and may vomit.

Typical attacks last from 60 to 90 seconds. Consciousness returns gradually.

Focal seizures may spread to involve both hemispheres, mimicking a

In simple partial focal seizures, the seizure remains localized, and

Complex partial seizures are focal seizures in which consciousness or

• Most seizures are followed by a period of postictal confusion and lethargy

• Pseudoseizures can be difficult to distinguish from true seizures and may

• In first onset seizure or unclear seizure history, more extensive studies

• A seizure may result in a lactate-driven, wide anion gap metabolic

• Management simultaneously focusing on identifying the reversible

• Antiepileptic agents, such as valproate, lamotrigine, topiramate,

• If the patient continues to seize despite initial therapy with

• If seizure activity continues, a careful reassessment should be done to

• Preparations for endotracheal intubation and administration of third –

- If seizure activity continues, a careful reassessment should be done to identify

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