Clinical Medicine 2018 Vol 18, No 5: 409–13 CME NEUROLOGY

Seizures and epilepsy in the acute medical setting:

presentation and management

Authors: Elizabeth Caruana GaliziaA,* and Howard John FaulknerB,*

Epileptic seizures are a common cause for presentation may be associated with a high mortality rate, likely reflecting a
high-risk subgroup of patients5 and not uncommonly presents with
ABSTRACT

to acute medical services. Whether presenting with an

isolated, unprovoked seizure or with status epilepticus, a myoclonic jerks, head turning, and other motor phenomena often
good understanding of seizures and their mimics ensures associated with epileptic seizures;6 Sheldon et al,7 proposed a series
appropriate investigation and treatment. This article of questions that they demonstrated would distinguish seizures
describes the practical aspects of the management of patients from syncope with 94% sensitivity and specificity (see Table 1).
presenting with seizures to the emergency department or the Raised prolactin (within 30 min) or lactate following loss of
acute medical unit. consciousness can contribute to the distinction between bilateral
tonic-clonic seizures and syncope or a non-epileptic attack, but
are less helpful in the differentiation of non-convulsive episodes
and are generally not recommended.8,9 Where the history is
Introduction
lacking, atypical, or inconclusive, early involvement of specialists
Seizures are one of the commonest causes of transient loss of experienced in the investigation and management of T-LOC
consciousness presenting to acute medical services and epileptic improves diagnosis.10
seizures are the commonest cause of short admissions among the
neurological conditions. While not all seizures are associated with First seizures
lost consciousness, most requiring acute medical care will involve
impaired awareness and responsiveness. Approximately 1% of the According to the National Institute for Health and Care
UK population are treated for epilepsy, with around 0.5 new cases Excellence (NICE) guidance,11 anyone with a suspected
per 1,000 population every year.1 Acute medical and emergency first seizure should be referred for specialist assessment
department physicians need a good working knowledge of the and seen within 2 weeks. Most patients with a single self-
management of seizures and to be aware of seizure mimics. terminating seizure who have made a full recovery can be
managed as outpatients through local first-seizure pathways.
Transient loss of consciousness
Transient loss of consciousness (T-LOC) is a common complaint Key points
that may present to many different specialties under various
labels, including ‘blackouts’, ‘seizure’, ‘blank spells’, and ‘falls’. 2
Transient loss of consciousness is common, with syncope,
The term T-LOC itself is non-specific and includes all causes of self-
epileptic seizures, and non-epileptic seizures accounting for most
limited loss of consciousness, regardless of mechanism.3 Syncope
presentations
is the commonest cause of T-LOC, followed by epileptic seizures
and non-epileptic seizures.3
A thorough history including a witness account will allow a History, including a witness account where possible, is key
diagnosis to be made in the majority of patients.4 Distinguishing
seizures from syncope and functional non-epileptic seizures can Consider urgent brain imaging in specific circumstances
be difficult, but these are equally important diagnoses to make.
Patients with functional non-epileptic seizures are often exposed Seizures may be provoked or unprovoked and identifying the
to inappropriate interventions and treatment with antiepileptic underlying cause has implications for treatment and onward
drugs. Diagnosing functional non-epileptic attack disorder and its referral
management are covered in detail elsewhere in this issue. Syncope
Status epilepticus is a medical emergency; timely treatment,
delivered in appropriate doses are paramount
Authors: Aconsultant neurologist, Department of Neurology,
Atkinson Morley Wing, St George’s Hospital, London, UK; Bconsultant KEYWORDS: seizures, epilepsy, status epilepticus, transient loss
neurologist, Department of Neurology, Southmead Hospital, Bristol, of consciousness, classification ■
UK; *authors contributed equally

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Table 1. The Sheldon questionnaire. The patient has Box 1. Indications for urgent brain imaging and/or
seizures if point score ≥1, and syncope if score is <1. hospital admission
The same questions can be asked of a witness Indications for urgent brain imaginga and/or hospital
Questions shown to distinguish seizures from Points admission
syncope (if yes) Acute head trauma
New onset focal neurologic deficit
At times do you wake with a cut tongue after your spells? 2 Altered mental status persists (behaviour or cognition)
At times do you have a sense of déjà vu or jamais vu 1 Recurrent events
before your spells?
Persistent headache
At times is emotional stress associated with losing 1
Anticoagulation
consciousness?
A history of immunodeficiency or malignancy
Has anyone noted your head turning during a spell? 1
Fever
Has anyone ever noted that you are unresponsive, 1
have unusual posturing or have jerking limbs Focal seizure (partial seizure)
during your spells or have no memory of your spells New neurological symptoms prior to the seizure
afterwards? (Score as yes for any positive response)
Patients in whom follow-up cannot be ensured
Has anyone ever noted that you are confused after a spell? 1 a
Urgent imaging is not required for syncope, non-epileptic seizures, or patients
Have you ever had lightheaded spells? −2 with well-characterised epilepsy or recurrent admissions with drug/alcohol-
provoked seizures in the absence of any additional reason to suspect new
At times do you sweat before your spells? −2 intracranial pathology
Is prolonged sitting or standing associated with your spells? −2
Reproduced with permission.7
Acute symptomatic seizures
This encompasses all seizures that occur in close association with a
Antiepileptic medication is not indicated for a single seizure,
brain insult. The International League Against Epilepsy (ILAE) has
unless investigations indicate a high risk of seizure recurrence.12
proposed specific parameters where seizures can be called acute
Other than in status epilepticus, starting antiepileptic drugs
symptomatic (see Table 2).14 In these circumstances treatment
should ideally be a specialist decision. In the interim, the patient
should not be initiated unless there are multiple seizures, or if the
should be given basic safety and driving advice.
patient is in status epilepticus, followed by prompt specialist input
> Driving: by law patients must refrain from driving until specialist with respect to continuation. The risk of seizure recurrence is often
assessment. If a seizure is confirmed, the Driver and Vehicle minimal so long-term treatment with antiepileptic drugs is not
Licensing Agency (DVLA) must be informed and a group 1 required.
licence will usually be revoked for a minimum of 6 to 12 months
(depending on the presence/absence of abnormalities on Seizures in known epilepsy
magnetic resonance imaging [MRI] / electroencephalogram
[EEG]). This is an extremely common scenario. Patients can present
> Safety and lifestyle: shower rather than bath; avoid heights / reporting deterioration in their usual frequency for a range of
dangerous equipment; occupational/parenting guidance; first reasons including:
aid in the event of recurrent events; and who to contact. > patient/family anxiety about perceived changes
> intercurrent infections / systemic illnesses
Investigations: who should have urgent brain > alcohol and recreational drug use
imaging and who should be admitted? > medication related: eg poor adherence, changes in formulation/
brand, during planned withdrawal / changes to medication,
All patients with a first seizure presentation should be
drug interactions with other prescribed and over the counter
investigated with routine blood tests to exclude infection or
medications
metabolic disturbance and should have an electrocardiogram
> new acute symptomatic seizures, for example due to a head injury.
(ECG). The majority of uncomplicated first seizure patients do
not require urgent brain imaging before discharge. MRI is the The history is key. Is the seizure pattern unusual for the
imaging modality of choice to investigate seizures and will patient? Ask how often seizures occur at their worst or their best.
be organised via a first seizure clinic. Urgent brain imaging Confusion about the patient’s normal seizure pattern can occur
(preferably with MRI, but with computed tomography [CT] if MRI in new environments, for example, a stranger may have called an
is not available / feasible acutely) before discharge should be ambulance unnecessarily. If the above precipitants have been
considered in those patients where an acute intracranial event is excluded, fluctuations in seizure frequency may occur simply due
suspected (see Box 1). to the natural variability of epilepsy.
Patients with abnormal imaging, prolonged or recurrent events, If adherence has been poor, try to establish why, in order to
or incomplete recovery may justify a brief admission for more address the root cause (eg side effects needing a change in drug/
urgent (inpatient) medical and neurological assessment.13 dose, forgetfulness – would a blister pack help?)

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and mortality if not controlled by 30 min. Treatment should be

Table 2. Parameters for acute symptomatic seizures
initiated at 5 min.
proposed by the International League against Most hospitals will have local protocols for the treatment
Epilepsy of convulsive status epilepticus. A typical protocol is shown
Provoking insult Time-frame in Fig 1: all involve initial treatment with benzodiazepines (in
adults typically up to 2 doses of 4 mg of lorazepam or 10 mg
Stroke/hypoxia <1 week
midazolam, which may include pre-hospital treatment by carers
Traumatic brain injury without <1 week or paramedics,11 followed by AEDs for ongoing seizures. Phenytoin
subdural haematoma and phenobarbitone are the only AEDs currently licensed in
Traumatic brain injury with subdural Up to 1 month this situation, with speed and adequate dosing (20 mg/kg for
haematoma phenytoin, 15 mg/kg for phenobarbitone) probably being more
important than choice of agent.
Intracranial surgery <1 week
Meta-analyses suggest equipotency of valproate (30–40 mg/
Arteriovenous malformation at time <1 week kg, max 3 g) and levetiracetam (40–60 mg/kg, max 4.5 g) with
of haemorrhage phenytoin, although these are not yet licensed for use in SE.17
CNS infection Until laboratory and Presently there is insufficient evidence to recommend either drug
clinical signs of infection ahead of existing therapies for management of SE pending the
have resolved outcome of ongoing trials.18 Those with ongoing seizures despite
appropriate treatment need urgent intervention with anaesthetic
Multiple sclerosis <1 week (of relapse)
agents and management on an intensive care unit with local
Alcohol withdrawal 7–48 hours from last neurology input.
alcoholic drink Non-convulsive status epilepticus (NCSE) is a more difficult
Serum glucose (within 24 hours) <36 mg/dL (2 mM) or diagnosis usually made based on EEG. Unlike CSE where early
>450 mg/dL (25 mM) and intervention is essential, aetiology is the principal determinant
ketoacidosis of outcome in NCSE rather than duration of seizures and thus
escalating treatment prior to EEG is not indicated without
Serum sodium (within 24 hours) <115 mg/dL (<5 mM)
specialist advice.16 Treatment usually involves the use of
Serum calcium (within 24 hours) <5 mg/dL (<1.2 mM) intravenous benzodiazepines under EEG control.
Serum magnesium (within 24 hours) <0.8 mg/dL (<0.3 mM)
Urea nitrogen (within 24 hours) >100 mg/dL (>35.7 mM) Classification
Creatinine (within 24 hours) >10 mg/dL (>884 uM) The classification of seizures and the epilepsies has recently been
Adapted with permission from Beghi et al, 2010.14 CNS = central nervous updated. A comprehensive review of the new classification is
system available on the ILAE website (www.ilae.org). Increasingly, one
will see, and should start to use, the following terms in clinical
practice:20
Investigations: ECG and screening bloods for sepsis and > ‘partial’ is replaced by the term ‘focal’; this can be further
metabolic causes should include antiepileptic drug (AED) levels qualified by whether awareness is retained or not, so that
where possible to assess adherence. Try to resist the temptation for ‘complex partial’ becomes ‘focal unaware’ and ‘simple partial’
brain imaging unless there is a clear clinical indication (see Box 1) becomes ‘focal aware’
and EEG is rarely useful in this situation. > ‘secondarily generalised’ is replaced by ‘focal to bilateral tonic
In addition to addressing the cause, management may involve clonic’
simple reassurance. > for generalised onset seizures, seizures can be described
Seek advice from the patient’s usual treating team or local as ‘generalised motor’, which would include tonic clonic
neurology services, but try to avoid escalating the dose of seizures, or ‘generalised non-motor’, which refers to
existing medications without specialist advice. If short-term ‘absences’
rescue medications are required for safe discharge, consider using > ‘unknown onset’ and ‘unclassified’ have been added, acknowledging
clobazam 10 mg at night as a temporary add-on therapy prior to that, not uncommonly, seizure onset and aetiology cannot be
specialist advice. defined.

Status epilepticus Conclusion

Status epilepticus (SE) is defined by 2 time points: the first time Seizures and seizure-mimics are common presentations to
point is when a seizure has failed to self-terminate and has emergency departments and acute medical units, either as
become ‘abnormally prolonged’ leading to the second time isolated events or as a medical emergency in status epileptics.
point when there is a risk of neurological damage and long- The history is key in the former situation, while speed in delivering
term consequences. SE may be convulsive or non-convulsive.15 appropriate treatment cannot be over-emphasised in the latter.
Convulsive SE (CSE) is a medical emergency, operationally Central to this is early input from the neurology or epilepsy team,
defined by tonic clonic seizures persisting (or recurring without that will guide appropriate investigation and, if indicated, the start
recovery) beyond 5 min, with an increasing risk of morbidity of treatment. ■

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Stabilise paent
Secure airway (recovery posion) and give oxygen
Call for help
Monitor vital signs and instute cardiac monitoring
Immediate measures Establish IV access and take venous blood samples for glucose, LFT, U+E, Mg2+, CA2+,
FBC, toxicology screening and anepilepc drug levels

If there are concerns about hypoglycaemia, poor nutrion or alcohol excess, give 250
mg of thiamine IV, followed by 50 mL of 50% glucose IV over 10 minutes (consider
1 mg IM glucagon if IV access not available)

Give IV lorazepam 0.1 mg/kg (max 4 mg) over a few seconds

If lorazepam is not available give diazepam 10 mg IV (0.15 mg/kg)

Fig 1: Algorithm for the treat- 5–20 min
If IV access is not possible give buccal midazolam 10 mg
ment of convulsive status epi-
lepticus. Adapted with permis- If no response repeat aer 10 min and inform intensive care unit (ITU)
sion from the American Epilepsy
Society guideline 2016.19 The
most important differential diag- If no response
nosis of status epilepticus is non-
epileptic seizures. Non-epileptic
seizures tend to last longer than Give phenytoin IV (20 mg/kg)
epileptic seizures and should be or one of:
considered as a diagnosis before 20–40 min
emergency antiepileptic drugs
phenobarbital IV (10–15 mg/kg)
sodium valproate IV (30–40 mg/kg, max dose 3,000 mg)
are administered. Alongside
leveracetam IV (40–60 mg/kg, max dose 4,500 mg)
treatment, urgent investiga-
tions must be performed to
confirm the cause of the status
epilepticus. CA2+ = calcium;
If no response
FBC = full blood count; IV =
intravenous; LFT = liver function Refractory status epilepcus
test; Mg2+ = magnesium; U+E = 40–60 min
urea and electrolytes; IM = intra- Intubate, give general anaesthesia and admit to ITU
muscular

8 Matz O, Zdebik C, Zechbauer S et al. Lactate as a diagnostic marker

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