Ver el código de «Seizure»

''This page covers <u>seizures in general</u>; refer to [[status epilepticus]] for persistently seizing patients and [[seizure (peds)]] for pediatric patients.''

==Background==
*Caused by a pathologic pattern of brain cortex activity (time-limited paroxysmal events from abnormal rhythmic neuronal discharges) → involuntary movement or change in level of consciousness<ref name="Martindale">Martindale JL, Goldstein JN, Pallin DJ. Emergency department seizure epidemiology. Emerg Med Clin North Am. 2011 Feb;29(1):15-27.</ref>
**11% of people will have at least one seizure in their lifetime
**3% will have epilepsy (at least 2 unprovoked seizures)
*In pregnancy >20 WGA or <4wks postpartum, need to consider [[eclampsia]]
**Most seizures in pregnancy are not first-time seizures, but rather are due to medication noncompliance or pharmacokinetic drug changes as result of pregnancy
*The most common etiology of seizure is noncompliance with medication

{{Seizure types}}

{{Clinical features seizure}}

===Seizure vs. Syncope<ref>Sheldon R et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3;40(1):142-8.</ref>===
*Factors that strongly favor seizure from most specific to least:
**Waking with cut tongue
**Abnormal behavior noted by bystanders
**[[syncope|LOC]] with emotional stress
**Postictal [[confusion]]
**Head turning to one side during LOC
**Prodromal deja vu or jamais vu
*Factors that predict against seizure
**Presyncopal spells
**Prodromal vertigo
**LOC with prolonged standing, sitting
**Diaphoresis, [[vertigo]], [[nausea]], [[chest pain]], feeling of warmth, [[palpitations]], [[dyspnea]] before spell

==Differential Diagnosis==
[[File:Seizure Causes.png|thumb|Differential diagnosis of seizures]]
{{Seizure DDX}}

==Evaluation==
===Physical===
*Check for:
**[[head injury|Head]] / [[cervical spine injuries|C-spine injuries]]
**Tongue/mouth lacs
***Sides of tongue (true seizure) more often bitten than tip of tongue ([[psychogenic nonepileptic seizure]], formerly "pseudoseizure.")
***Tongue biting has sensitivity of ~25% and approaches 100% specificity in lateral tongue biting<ref>Benbadis SR et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27;155(21):2346-9.</ref>
**[[Posterior shoulder dislocation]]
**[[focal neuro deficit|Focal deficit]] (Todd paralysis vs [[CVA]])
*** If new, treat as presumed stroke. Cannot be ruled as Todd's without stroke workup.
**Nuchal rigidity (concern for [[meningitis]])

===Work-Up===
====[[First-time seizure|First-Time Seizure]] or Change in Baseline Seizures====
*Non-contrast [[head CT]] in ED (or advanced imaging arranged as outpatient)
**First time seizures in setting of EtOH or [[Alcohol withdrawal seizures|EtOH-withdrawal]]: 6.2% had clinical significant lesion.<ref>Earnest MP, et al. Neurology 1988;38:1561–5.</ref>
*Point-of-care glucose
*Pregnancy test
*CBC & chemistry
*[[ECG]] ([[prolonged QT]] and [[torsades]] can cause shaking after intermittent runs}
*Consider prolactin<ref>Fisher RS. Serum prolactin in seizure diagnosis: Glass half-full or half-empty?. Neurol Clin Pract. 2016;6(2):100-101.</ref> or [[lactate]] to assist in differentiating seizures from [[psychogenic nonepileptic seizure]] or volitional seizure activity (lactate may be detectable for up to 1 hour post-seizure)
*Consider: [[Utox]], RPR, [[HIV]], [[UA]], EEG, [[lumbar puncture]], EtOH level, CK

====Known Epileptic with NO Change in Baseline Seizures====
*[[Anticonvulsant levels and reloading|Anticonvulsant drug concentration]]
*Point-of-care [[hypoglycemia|glucose]]
*Trauma workup, if appropriate
*Consider [[head CT]] scan if prolonged postictal period or trauma

==Management==
[[File:Seizure Management.png|thumb|Management of seizures]]
{{Seizure actively seizing management}}

==Disposition==
===[[First-time seizure|First-Time Seizure]]===
*Those with single generalized seizure and otherwise normal history and physical can be discharged home with close follow-up<ref>Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2014;63(4):437-47.e15. doi:10.1016/j.annemergmed.2014.01.018</ref>
**Observation is not unreasonable for those that look ill or have a complicating history/physical (comorbidities, age > 60y, cancer, immunocompromise, cardiovascular disease)
**24-hr recurrence of seizures in this group is about 9% when alcohol-related events are excluded<ref>Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2007; 69(21):1996-2007.</ref>
*Instructions not to drive, swim, or participate in other potentially dangerous activities is important
*Outpatient neurology follow-up

==See Also==
*[[Anticonvulsants]]
*[[Anticonvulsant levels and reloading]]
*[[Seizure (peds)]]
*[[Febrile seizure]]
*[[Status epilepticus]]
*[[Alcohol withdrawal seizures]]

==External Links==
*[http://ddxof.com/seizure-2/ DDxOf: Differential Diagnosis of Seizures]
*[https://www.acep.org/patient-care/clinical-policies/seizure/ ACEP Clinical Policy on Seizure]

==References==
<references/>

[[Category:Neurology]]