0071643192.pdf

Generalized Seizures

Primary generalized seizures begin in both hemispheres and do not have
inciting focus. All except myoclonic have altered LOC.

SYMPTOMS/EXAM

■ Nonconvulsive (absence or petit mal)
■ Alteration in mental status without motor activity
■ Most frequent in 5- to 10-year-olds
■ Rarely postictal
■ Characterized by brief 3-Hz, spike-and-wave discharges on EEG
■ Convulsive (grand mal)
■ Abrupt loss of consciousness at onset (except with myoclonic)
■ Can be clonic, tonic, tonic-clonic, myoclonic or atonic
■ Followed by postictal state
■ Todd’s paralysis: Focal paralysis, typically following a generalized seizure;
usually lasts 1–2 hours but may last 1–2 days

DIFFERENTIAL

■ Primary considerations include syncope, dysrhythmia, psychiatric illness,
decerebrate posturing, migraines.

DIAGNOSIS

■ EEG during event confirms diagnosis (if diagnosis is in question).
■ ED evaluation may be limited (known seizure disorder) or extensive
(seizure in febrile immunocompromised patient).
■ First-time seizure
■ Check sodium and glucose.
■ Check urine toxicology.
■ CT scan if anysuspicion for serious structural lesion
■ LP if anysuspicion for meningitis or subarachnoid hemorrhage
■ Recurrent seizure
■ Check glucose and anticonvulsant levels (if available).
■ Supratherapeutic levels of phenytoin and carbamazepine can result
in seizures.
■ More extensive evaluation is necessary if change in seizure pattern,
prolonged postictal state, fever, etc.
■ Status epilepticus (see “Status Epilepticus”)

TREATMENT

■ First-time seizure
■ Treat underlying cause, if identified.
■ If CNS lesion present, initiate anticonvulsant therapy.
■ Otherwise recommend outpatient follow-up for MRI and EEG if no
cause found.
■ Alcohol withdrawal seizure: Treat with benzodiazepines; patients do
not require chronic anticonvulsant therapy
■ Ongoing seizures (see “Status Epilepticus”)

Status Epilepticus

Seizure lasting >30 minutes or recurrent seizures without resolution of postictal
state; may be generalized seizures (life-threatening, high mortality), absence
seizures, or complex partial seizures

NEUROLOGY

Nonconvulsive (absence)

seizures typically develop in

childhood.

Serum lactate may be

elevated immediately

following a generalized tonic-

clonic seizure, but should

clear spontaneously within

1 hour.

The blood prolactin level may

be elevated for 15—60 minutes

following generalized seizure.