Chief Corner: Seizures

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My patient is seizing !!!

Last week at Expert Noon Report, we discussed seizure and it’s acute management.

Let’s talk about it!

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How to recognize epileptic versus non-epileptic seizure clinically?

Epileptic

  • Eyes open

  • Head turn, gaze deviation

  • One sided jerking or all 4 limbs

  • Unresponsive

  • Rhythmic jerking

Non-epileptic

  • Eyes closed

  • Pelvic Thrusting

  • Arrhythmic jerking

  • Bilateral arms/legs

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A history is key!

Ask about potential provoking factors: dehydration, lack of sleep, intoxication, withdrawals.

Work up: first time seizure requires EEG and MRI (can be outpatient) to risk-stratify to determine indication for AED.

Acute Management:

Most seizures burn out on their own in 2-5 minutes.

If still seizing after 2 min, give 2-4 mg IV Ativan — rate limit on this treatment is respiratory status!

Call neurology consult! This should be a STAT page.

Common AEDs that neurology may instruct you to load:

  • Fosphenytoin 20 mg/kg (can cause hypotension; do not use if hypotensive)

  • Depakote 40 mg/kg

  • Keppra 60 mg/kg (max dose 4 mg IV)

    With Fosphenytoin and Depakote, must get a post load level 1-2 hours after load (total level; not free level)

Let’s talk status:

Convulsive status epilepticus: +/- use of cvEEG 

  • this is an emergency

  • >5 minutes of convulsions

Non-convulsive status epilepticus (NCSE): requires a cvEEG for diagnosis

  • No clinical signs or subtle signs of seizure (nystagmus, hippus, gaze deviation)

  • Often AMS is presenting symptom

  • Most of the time patients are unable to follow commands

  • 50-60% of patients have hx of seizures/epilepsy

  • Can be associated with use of beta-lactam Abx (cefepime)

    Focal motor status: cvEEG not required

  • Often rhythmic twitching of face/arm/leg on one side

  • retained consciousness, follows commands

  • not dangerous, non-emergency

  • treat with sodium channel blocker (vimpat, fosphenytoin, Trileptal)

EEGs:

cvEEG or continuous EEG

  • Only can be ordered by neurology or NSGY

  • Indications: NCSE, paralyzed/sedated patient and unable to follow exam, post-arrest cooling patient, spell capture

routine EEG

  • Internal Medicine can order

  • Indications: can be utilized to risk stratify after suspected or confirmed seizure for AED use.

AED (antiepileptic drugs)

Most common agents: Levetiracetam/Keppra, Lacosamide/Vimpat, Valproic Acid/Depakote, Phenytoin/Dilantin, Carbamazepine/Tegretol

Keppra:

  • Renally cleared, minimal interactions

  • Load 2 - 4g, maintain ~ 1 g BID

  • PO:IV conversion is 1:1

  • Associated with agitation, psychiatric mood dysregulation

Vimpat:

  • Used for status epilepticus, expensive

  • Load 200 mg, then maintain 100 mg BID

  • PO:IV conversion is 1:1

  • Associated with PR interval prolongation, dizziness, GI complaints

Depakote:

  • used for all seizure types, interacts with many drugs

  • Load 40 mg/kg, maintain with 250 mg BID (titrate upto 2000 mg/day max)

  • Associated with abnormal LFT, thrombocytopenia, teratogenic

Dilantin:

  • older drug, many drug interactions 2/2 CYP450 inducer therefore rarely used except for refractory status epilepticus

  • Load 20 mg/kg

Tegretol:

  • Potent enzyme inducer; many drug interactions

  • Used for focal or GTC, but worsens absence, myoclonic, and atonic seizures

  • Target dose: 400-800 mg/day

  • Associated with abnormal liver, cbc labs. GI symptoms, hypoNa. For people of Asian descent, must assess HLA B*1502 as this drug can cause severe hypersensitivity reaction.

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Internal Medicine Chiefs