Rosen & Barkin's 5-Minute Emergency Medicine Consult (638 page)

Febrile seizures are generalized seizures occurring between 3 mo and 5 yr of age:

• Typically lasts <15 min
  
• Associated with a rapid rise in temperature
  
• Without evidence of CNS infection or other definitive cause
  

• Hypoxia
  
• Hypertensive encephalopathy
  
• Eclampsia
  
• Infection:
  
  • Meningitis
    
  • Abscess
    
  • Encephalitis
    
• Vascular:
  
  • Ischemic stroke
    
  • Hemorrhagic stroke
    
  • Subdural hematoma
    
  • Epidural hematoma
    
  • Subarachnoid hemorrhage
    
  • Arteriovenous malformation
    
• Structural:
  
  • Primary or metastatic neoplasm
    
  • Degenerative disease (i.e., multiple sclerosis)
    
  • Scar from previous trauma
    
• Metabolic:
  
  • Electrolytes
    
  • Hypernatremia
    
  • Hyponatremia
    
  • Hypocalcemia
    
  • Hypo/hyperglycemia
    
  • Uremia
    
• Toxins/drugs:
  
  • Lidocaine
    
  • Tricyclic antidepressants
    
  • Salicylates
    
  • Isoniazid
    
  • Cocaine
    
  • Alcohol withdrawal
    
  • Benzodiazepine withdrawal
    
• Congenital abnormalities
  
• Idiopathic
  
• Trauma
  

DIAGNOSIS

• Altered level of consciousness
  
• Involuntary repetitive muscle movements:
  
  • Tonic posturing or clonic jerking
    
• Seizures of abrupt onset:
  
  • Aura may precede a focal seizure
    
• Duration usually 90–120 sec:
  
  • Impaired memory of the event
    
  • Postictal state is a brief period of confusion and somnolence following a seizure
    
• Evidence of recent seizure activity:
  
  • Confusion or somnolence
    
  • Acute intraoral injury
    
  • Urinary incontinence
    
  • Posterior shoulder dislocation
    
  • Temporary paralysis (Todd paralysis)
    
• Other findings may suggest etiology of seizure:
  
  • Fever and nuchal rigidity (CNS infection)
    
  • Needle tracks; stigmata of liver disease (drugs and alcohol)
    
  • Head trauma:
    
    • Papilledema (increased intracranial pressure)
      
    • Lateralized weakness, sensory loss, or asymmetric reflexes
      

• History of seizures:
  
  • Medication compliance
    
• Recent illness
  
• Head trauma
  
• Headaches
  
• Anticoagulation therapy
  
• Fever
  
• Neck stiffness
  

• Complete neurologic exam:
  
  • Todd paralysis
    
• Complete secondary and tertiary survey to evaluate for any trauma secondary to seizure or potential cause for seizure
  

• A thorough history is the most valuable part of the workup:
  
  • Witness accounts
    
  • History of prior seizures
    
  • Presence of acute illness
    
  • Past medical problems
    
  • History of substance use
    
• Patients with chronic seizure disorder and typical seizure pattern may need to have only serum glucose and anticonvulsant levels checked
  
• New-onset seizure mandates workup:
  
  • Electrolytes including calcium, phosphorus
    
  • Head CT
    
  • Toxicology screen
    
  • Pregnancy test if woman is of childbearing age
    
  • Lumbar puncture indicated if:
    
    • New-onset seizure with fever
      
    • Severe headache
      
    • Immunocompromised state
      
• Persistently altered mental state:
  
  • Search for specific underlying cause
    
  • Patient’s condition and resources for follow-up determine whether all these tests must be done in the ED
    

• A child with a 1st febrile seizure should receive fever workup as dictated by clinical condition
  
• Inquire about family history of febrile seizures
  
• Labs and radiographs as needed to determine source of fever
  
• Lumbar puncture for 1st febrile seizure:
  
  • Consider if age <1 yr
    
  • Ill appearing
    
  • Lethargy or poor feeding
    
  • Exam difficult
    
  • Unreliable follow-up
    

• Serum anticonvulsant levels
  
• Blood–alcohol level
  
• Toxicology screen
  
• CBC:
  
  • WBC often elevated
    
• Chemistry panel:
  
  • Bicarbonate often low
    
• Lactate may be elevated
  
• CSF:
  
  • May have transient increase in WBC to 20/μL
    

• Noncontrast head CT:
  
  • Persistent or progressive alteration of mental status
    
  • Focal neurologic deficits
    
  • Seizure associated with trauma
    
• CT scan with contrast should be obtained in HIV-positive patients to rule out toxoplasmosis
  
• MRI is sensitive for low-grade tumors, small vascular lesions, early inflammation, and early cerebral infarcts:
  
  • Consider electively in new-onset seizures
    

• EEG may be arranged with neurology on an outpatient basis
  
• Bedside EEG may be performed in ED if there is suspicion of nonconvulsive status epilepticus or psychogenic seizures
  

• Syncope (may also have incontinence, twitching, and jerking)
  
• Hyperventilation syndrome
  
• Psychogenic seizures
  
• Transient ischemic attacks
  
• Sleep disorders
  
• Delirium tremens
  
• Hypoglycemia
  

TREATMENT

Anticonvulsant as per local protocol

• Airway management as indicated
  
• Pulse oximetry, oxygen with suction available:
  
  • C-spine precautions
    
  • Rapid-sequence intubation if patient cannot protect airway or with hypoxia or major head trauma
    
  • IV access, rapid determination of serum glucose:
    
    • If hypoglycemic, give IV dextrose 25 g
      
  • Lorazepam or diazepam for active seizures
    
  • Naloxone if concern for narcotic overdose
    

• 1st-time seizure:
  
  • Normal head CT if performed
    
  • Return to baseline with normal neuro exam:
    
    • Discharge with close follow-up with PCP and/or neurologist
      
• 1st-time seizure:
  
  • Structural lesion on CT or MRI:
    
    • Start antiepileptic drug (AED) in consultation with PCP and/or neurologist
      
• Recurrent seizure not on AED:
  
  • Start AED in consultation with PCP and/or neurologist
    
• Recurrent seizure with subtherapeutic AED level:
  
  • IV and/or PO load current AED
    
• Recurrent seizure with therapeutic AED level:
  
  • Need careful evaluation for cause of seizures, new lesions, etc.:
    
    • Adjust and/or add AED in consultation with neurologist
      
• Seizure in a pregnant patient:
  
  • Evaluate as other seizure patients
    
  • Strongly consider eclampsia if >20-wk gestation
    
  • OB consultation, arrange for C-section
    
  • Magnesium
    
• Seizures related to alcohol:
  
  • Determine if seizure is caused by withdrawal (typically 6–48 hr after cessation of drinking) or another cause
    
  • Management of withdrawal seizures is benzodiazepines
    

• Fever control with acetaminophen and ibuprofen
  
• Anticonvulsants not needed for febrile seizures
  
• Anticonvulsants should be prescribed in conjunction with neurologist.
  

• Acetaminophen: 500 mg PO/PR q4–6h; do not exceed 4 g/24 h
  
• Diazepam: 0.2 mg/kg IV per dose; 0.5 mg/kg PR
  
• Fosphenytoin: 15–20 mg/kg phenytoin equivalents (PE) at rate of 100–150 mg/min IV/IM
  
• Ibuprofen: 5–10 mg/kg PO
  
• Levetiracetam: Start 500 mg PO/IV q12h (peds: Start 20 mg/kg/d PO div. BID; age 4–15 yr)
  
• Lorazepam: 2–4 mg IV/IM (peds: 0.05–0.1 mg/kg IV per dose)
  
• Naloxone: 0.4–2 mg IV/IM/SQ (peds: 0.1 mg/kg IV/IM/SQ)
  
• Phenobarbital: 15–20 mg/kg IV at rate of 1 mg/kg/min (plan to protect airway)
  
• Phenytoin: 15–20 mg/kg IV at rate of 40–50 mg/min (peds: Use rate of 0.5–1 mg/kg/min)
  
• Propofol: 5–50 μg/kg/min IV, titrate to effect (plan to protect airway)
  
• Valproate sodium: 10–20 mg/kg/d
  

Benzodiazepines

• Fosphenytoin
  
• Levetiracetam
  
• Phenobarbital
  
• Phenytoin
  
• Propofol
  
• Valproate sodium:
  
  • works as well as second line agent in status epilepticus and can be given faster
    

FOLLOW-UP