Krishna Chinthapalli In England, suspected seizures account for almost 3% of all ambulance responses and between 0.71 and 3% of Accident and Emergency Department (A&E) attendances. Nearly half of the people presenting to A&E with seizures are admitted to a hospital bed.1 If encountering a suspected seizure in either a prehospital or hospital environment, the priority is to apply resuscitation principles. Confirm the airway is clear, but refrain from using airway adjuncts or forcibly opening the mouth during a convulsion, to prevent injury. For prolonged convulsions, intubation should be considered. In the hospital environment, administer high‐flow oxygen using a non‐rebreathing face mask, and establish intravenous access for rapid medication delivery. If malnutrition or chronic alcohol misuse is suspected, 250‐500 mg intravenous thiamine should be given. Blood glucose should be measured as soon as possible. If it is low (< 4 mmol/l) or hypoglycaemia is strongly suspected, 1 mg of intramuscular glucagon or an intravenous 10–20% glucose infusion is administered. If a convulsive seizure lasts over 4–5 minutes, a benzodiazepine should be administered as per protocols for status epilepticus. Intravenous lorazepam 4 mg (0.1 mg/kg if under 40 kg) or diazepam 10 mg are preferred options. If intravenous access is not available, buccal midazolam 10 mg (approximately 0.3 mg/kg if the person weighs less than 30 kg), rectal diazepam 10 mg, or intramuscular midazolam 10 mg are options. Hospital staff should verify that all prehospital medications have been administered as appropriate. During the initial management, the provider should consider some key questions: The differential diagnosis of epileptic seizures includes vasovagal syncope, cardiac syncope, dissociative seizures, movement disorders, migraine auras and transient ischaemic attacks. See Chapter 10, first seizure clinic. Getting an eyewitness account is crucial. If available, video recordings from mobile phones or security cameras can be invaluable. When gathering details, the questions should include duration, whether the eyes were open, any vocalisations, breathing pattern, and whether there was tongue or cheek biting. Note any pallor or cyanosis, posturing, automatisms, movements, incontinence and injuries. One should ask about the recovery period and any postictal symptoms such as confusion, headaches, focal weakness and aphasia. If the seizure occurs in hospital, carefully document these details: pupil size and position, Glasgow Coma Scale score, heart rate, and pulse oximetry. Obtaining consent for video recordings, either before or between seizures, is recommended as they are helpful in the diagnosis, especially if dissociative seizures are suspected. Certain features can help distinguish dissociative seizures, such as a duration of more than 5minutes, fluctuating and asynchronous movements, pelvic thrusting, forced eye closure, and signs of preserved awareness. Accurately timing the event is essential not just for diagnosis but also for administering benzodiazepines promptly to prevent status epilepticus. A detailed history should be obtained whenever possible from the person, any carers, or contacts. This should include details of previous neurological illnesses or surgery, other medical conditions, current and recent medications, alcohol and drug use, and any possible previous seizures or collapses. In people with known epilepsy, one should also ask about the age of epilepsy onset, seizure types, usual triggers, previous and current anti‐seizure medications (ASM), and dosages and timings. Obtaining details of the person’s usual neurology providers means that clinical information can be obtained and the usual team informed of the admission. Triggers should be considered. In people with known epilepsy, missed ASM doses or recent medication changes are essential to consider. Other factors to enquire about are fever, infectious symptoms, lack of sleep, alcohol or illicit drug use, alcohol withdrawal, recent prescription medicine changes, head trauma and focal neurological symptoms. Preceding aura or focal seizure symptoms help classify the type of seizure. De novo seizures occurring during an admission are most commonly due to stroke, electrolyte/glucose abnormalities or other medications.2 These tend to occur in older people. If provoked by specific factors, they are less likely to require long‐term ASM. Following a seizure, a neurological examination is crucial. The extent of postictal confusion or behavioural changes should be assessed. Confusion gradually improves and lasts for under an hour after a convulsion. However, status epilepticus, intubation, benzodiazepine use, and older age can significantly prolong confusion.3 Prolonged or fluctuating confusion warrants prompt investigation for non‐convulsive status epilepticus (NCSE), encephalitis or an underlying encephalopathy. Subtle repetitive eye, eyelid or limb movements and automatisms may indicate NCSE.4 Focal neurological deficits may point towards a stroke or space‐occupying lesion. An examination, checking for an irregular pulse and hypotension, may indicate cardiac syncope. Pulse, blood pressure, and ECG recording are mandatory for people with possible cardiac disease. Injuries are common in people with epilepsy, with one study suggesting that almost one in five sustains an injury annually.5 While most injuries are minor, such as contusions and lacerations, seizures can also lead to burns, joint dislocations, fractures, and dental injury. A decreased or increased body temperature may indicate sepsis. A blood work‐up may include point‐of‐care tests, such as a blood gas analysis. This allows for rapid measurement of blood glucose and electrolytes. Raised lactate and lowered pH are typically seen after convulsions, and are less likely after syncope or dissociative seizures. Serum prolactin is no longer recommended, but it is raised within 20 minutes after a convulsive seizure. Blood tests should include measurement of glucose, sodium, calcium, and magnesium. Full blood count and C‐reactive protein may be abnormal in infections. Kidney and liver function testing will aid in the choice and dosing of ASM. Thyroid profiling is not mandatory, but thyrotoxicosis can trigger seizures, and there are case reports of myxoedema coma leading to hyponatraemia and seizures. Pregnancy testing should be performed in women of childbearing age. Pregnancy may lead to seizures due to eclampsia, reduced serum ASM levels, hyperemesis gravidarum or thrombosis. Certain drugs, such as sodium valproate, should be avoided in pregnancy. Toxicology testing is indicated if there is suspicion of alcohol overuse or illicit drug use. After a convulsive seizure, it is common to find raised blood glucose and neutrophil count as part of an acute stress response. In people with epilepsy who are taking ASM, it is helpful to measure ASM levels on admission to assess if a lack of adherence played a role.
CHAPTER 13
Epilepsy in the Acute Medical Unit
IMMEDIATE MANAGEMENT
HISTORY
EXAMINATION
BASELINE INVESTIGATIONS
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