Seizures (Seizure Disorder) — Symptoms and Treatment The main excitatory neurotransmitter in the brain is 

glutamate.
Overview Gamma-aminobutyric acid (GABA) is the principal inhibitory
neurotransmitter in the brain. An abnormality in the receptors
The term epilepsy refers to recurrent, unprovoked seizures that of these neurotransmitters might result in repeated, abnormal
can result from a known or an unknown cause. electrical discharges that are responsible for the
seizure. The seizure semiology depends on the extent of the
A patient diagnosed with epilepsy who presents with a abnormal neuroelectrical activity propagation.
seizure is considered an epilepsy emergency.
The most common causes of a seizure are:
A seizure is not necessarily motor; it is defined as an episode
of neurologic dysfunction caused by abnormal neuronal  Medical noncompliance in a patient with a known
activity. It can be characterized by a sudden change in senses, history of an epilepsy disorder
perception, or behavior. A convulsion is a seizure occurrence
with motor activity.  Stress
 Lack of sleep
A seizure may be focal or generalized. A focal seizure occurs
in one part of the brain, while a generalized seizure begins in  Caffeine use
one part of the brain but then spreads to both sides.
A new-onset seizure disorder may be the first presentation of
an epilepsy disorder. Epileptic seizure activity mostly
originates from a discrete region of the cortex in the initiation
phase that is characterized by two events in an aggregate of
neurons, i.e., a high-frequency burst of action potential and
hypersynchronization.

Later, the effect then spreads to other brain areas during the
propagation phase. This leads to increased levels of NMDA
and Calcium ions that exacerbate the situation due to enhanced
neurotransmitter release.

Neurotransmitters Increased sympathetic Increased autonomic

disturbed stimulation stimulation
Status epilepticus is a state of recurrent/ prolonged seizures
without a return to consciousness for more than five minutes.
Epilepsy syndrome is a clinical entity of consistent clinical Increased excitatory
neurotransmitters:
-Increased temperature -Urinary and fecal
incontinence
features, such as the age of presentation, EEG pattern, seizure
-Elevated lactic acid
type, and response to antiepileptic medications. - Acetylcholine -Tongue biting

-Increased heart rate and

When a patient is having a seizure, the term ictus is used to -Glutamate respiratory rate -Possible airway issue

describe the period of seizing. The term postictal refers to the

period that follows the seizure. An overview: Epidemiology of Epilepsy and Seizures

 Ictal period: Time when a seizure occurs Up to 200,000 new cases of epilepsy or seizures occur in the
United States each year. Half of these cases will be classified
 Post-ictal period: Period of altered mental status as an epilepsy disorder once the seizures recur. In the United
following a seizure States, 50,000 to 150,000 patients will reach status epilepticus,
which is an epilepsy emergency, every year. The most
 Status epilepticus: Seizure activity > 5 minutes OR
important risk factors for epilepsy and new-onset seizure
recurrent seizure activity without return to baseline
disorder include head trauma, history of stroke, and a family
mental status
history of epilepsy.
 Epilepsy: Unprovoked seizure
Pathophysiology of Seizures The risk of a recurrent seizure after the first seizure overall is
around 40%. A recurrent seizure after a first seizure will most
Because a seizure is characterized by abnormal neuronal commonly occur in the first six months.
activity, one expects to find abnormalities in the
neurotransmitters and their receptors in the brains of patients Clinical Presentation of Epilepsy and Seizures in the
with epilepsy. It is currently accepted that patients who have Emergency Department
seizures have an abnormal balance between excitatory
neurotransmitters and inhibitory neurotransmitters. When a patient presents to the emergency department with a
seizure, it is important to establish whether it is the first
seizure or a recurrent one.  If the patient has a known history
of an epilepsy disorder, compliance with antiepileptic a non-contrast computed tomography scan as soon as
medications should be checked. When a patient presents possible while at the emergency department. The rationale
with a new-onset seizure disorder in an emergency setting, behind this recommendation is to exclude life-threatening,
a medical history, physical examination, and workup should catastrophic causes of seizures, such as intracranial
be completed to rule out other causes, such as stroke, brain hemorrhage.
tumor, intracranial hemorrhage, trauma, hypoxia, vascular
abnormality, hypoglycemia, electrolyte disturbances, Patients presenting with a first-time generalized tonic-clonic
meningitis, encephalitis, alcohol or medication withdrawal, seizure who have returned to normal and have no neurological
drug-induced seizures, and malaria. deficits on their examination should receive a computed
tomography scan of the head. However, this can be done in an
Early posttraumatic seizures can occur in patients with outpatient setting. If computed tomography is available at the
severe traumatic brain injuries, especially if the patient emergency department, all patients presenting with seizures
developed an intracranial hemorrhage. Using prophylactic should be screened even if they have returned to a normal
antiepileptics in patients with severe traumatic brain injuries baseline.
might have a small role in reducing the risk of early
posttraumatic seizures. In this scenario, prophylactic
antiepileptics do not affect the risk of late posttraumatic
seizures.

Intracranial hemorrhage, whether traumatic or spontaneous,

can predispose the patient to an increased risk of seizures. The
sizes and locations of such bleeds are key factors in defining
the risk of seizures. Large temporal lobe intraparenchymal
bleeds are more likely to result in seizures than small deep
intraparenchymal bleeds.

Medication history is important in the emergency department

setting when dealing with a patient who is presenting with
seizures. Tricyclic antidepressants and isoniazid overdose can
cause seizures.

The physician should also try to characterize the seizure

activity by its duration, manifestation, associated warning
signs, such as photophobia, and interictal occurrences, such as
tongue biting, eye-rolling, and excessive salivation.
 Image :  “An electroencephalogram of a person with
Laboratory Investigations in Patients Presenting with Seizures childhood absence epilepsy showing a seizure”  by Der
to the Emergency Department Lang.  License: CC BY-SA 2.0

Laboratory tests have a small role in the diagnostic workup of Patients who have a history of malignant disease or
a patient presenting with seizures. It is important to exclude immunocompromise, or who receive anticoagulation therapy,
hypoglycemia/hyperglycemia and electrolyte and present with new-onset seizures should receive a
abnormalities as potential causes of seizures in any patient computed tomography scan at the emergency department.
presenting with a new-onset seizure disorder. Up to 15% of Those presenting with new-onset seizures and new-onset
those presenting with a new-onset seizure disorder have neurological deficits should also receive a computed
abnormal results in their laboratory testing. Women presenting tomography scan at the emergency department.
with seizures should receive a pregnancy test to exclude pre-
eclampsia and eclampsia, both of which occur in pregnant Patients in status epilepticus should also receive a phalography
women. (EEG) study if available at the emergency department. This is
important because an EEG can identify whether the problem is
Patients with new-onset persistent fever, severe headache, focal or generalized and can provide valuable information
altered mental status examination, and new-onset seizures about the prognosis.
should receive a lumbar puncture to exclude
meningoencephalitis. Treatment of Seizures at the Emergency Department

Imaging Studies in Patients Presenting with Seizures to the Any patient presenting with status epilepticus should receive
Emergency Department early and prompt treatment to halt the status epilepticus. When
a patient presents to you with seizures at the emergency
All patients with new-onset seizures or those presenting with department, three important points should be emphasized
status epilepticus to the emergency department should receive before treating the patient:
 1. A patient with an altered mental status or in a coma
might have non-convulsive seizures. An EEG can
confirm this diagnosis.
2. Aggressive control of the seizure is recommended to
avoid permanent neurological damage.
3. Identifying the etiology of the seizure is essential for
proper management after the patient is discharged
from the emergency department.

Any patient presenting with a seizure to the emergency

department should receive ABCDE care. Temperature
assessment and blood glucose levels should be determined in
all patients presenting with seizures to the emergency
department. Intravenous access is recommended for all
patients in the emergency department setting.

Benzodiazepines should be administered intravenously,

intramuscularly, or rectally, especially in those with prolonged
seizures or status epilepticus. Lorazepam is the
benzodiazepine of choice in managing seizures in an
emergency setting. Intranasal midazolam or rectal diazepam
are also good options for the emergency care of a patient
presenting with a seizure.

If benzodiazepines fail to control the seizures in the

emergency setting, phenytoin should be administered. Patients
who do not respond to benzodiazepines and phenytoin are
diagnosed with refractory status epilepticus.

Patients diagnosed with refractory status epilepticus should

receive barbiturates or Propofol. The aim is to limit the
duration of the seizure below five minutes if possible and
below 20 minutes in all patients. Phenobarbital is a reasonable
option for patients with refractory status epilepticus.

First-time seizure Known seizure

disorder

 Close outpatient  Check

follow up medication
levels
 No initiation of
antiepileptic  Load or
treatment administer
recommended medications as
needed