Subtypes

Partial

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  Simple partial

  
  
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  Complex partial

Generalized

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  Absence (petit mal)

  
  
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  Atypical absence

  
  
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  Myoclonic

  
  
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  Tonic-clonic (grand mal)

  
  
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  Status epilepticus

Etiology

Trauma: head trauma, stroke, hemorrhage, anoxia, neurosurgery

Mass lesions: arteriovenous malformations (AVM), tumor, cysticercosis

Infection: encephalitis, meningitis, AIDS

Medications: penicillin, quinolones, metronidazole, INH, tricyclic antidepressants, lithium, antipsychotics (e.g., clozapine), bupropion, cyclosporin, cocaine, PCP

Drug-induced: alcohol, barbiturates, benzodiazepines, change in anticonvulsant drug levels

Metabolic: hypo- or hyperglycemia, electrolyte disturbance, hypoxia, uremia, hepatic disease

Psychiatric: nonepileptiform (of note, a significant percentage of patients have comorbid epileptiform and nonepileptiform seizures), somatoform disorders, anxiety disorders such as panic disorder, psychosis

Degenerative disorders

Vascular diseases

Clinical features

+/− aura and/or psychic symptoms (e.g., déjà vu)

Automatism (e.g., lip smacking)

Dystonic posturing

Twitching

Staring

Deviation of head and eyes

Impaired/loss of awareness (e.g., complex partial and generalized seizures)

Myoclonic activity

Tonic-clonic activity

Exam findings

Tongue/buccal injury due to biting

Urine/bowel incontinence

Postictal confusion

Postictal sleepiness

Postictal agitation

Transient neurologic deficit

Seizure-induced trauma

+/− aspiration

Acute management

Consult neurology

Maintain airway, breathing, circulation

Position patient onto left side with head down

Assess vital signs and pulse oximetry, obtain brief history and perform focused exam

Establish IV access

Check fingerstick glucose

Immediate labs to consider include:

Chemistry panel, Ca, Mg, PO4, complete blood cell count with differential, antiepileptic drug levels, hepatic function, toxicology screen, blood alcohol level

Administer thiamine 100 mg IV before dextrose 50 ml 50% dextrose

Consider lorazepam 0.1mg/kg at 1-2 mg/min IV; monitor closely for respiratory depression

Status epilepticus—seizure >5 min or incomplete recovery of consciousness between 2 seizures

Medical emergency—Call 911/institute code blue/call neurology immediately

Lorazepam 0.1 mg/kg IV at 1-2 mg/min (max 4-6 mg in adults but increased risk of respiratory depression at higher doses); may repeat q5-10 min (max 80 mg/24 h)

Diazepam 5-10 mg IV at 1-2 mg/min; may repeat q5-10 min (max 100 mg/24 h)

Other anticonvulsants that may be used for seizure control include phenytoin, fosphenytoin

Continuously reassess need for intubation