Seizure Management in the ER

So what are some of the causes that may present seizures to us.

Obviously there are seizure disorders, like epilepsy. Trauma, specifically head injuries can cause seizures. Ever see those movies when a guy gets hit on the head and starts convulsing. That’s actually based in some medical science. Hypoxia and stroke can both prevent oxygen from getting to the brain, causing seizures. In addition to oxygen, the brain really likes glucose and salt so when we start to take those away, more seizures. And then there is the concern of infections like meningitis, encephalitis or a brain abscess which can all cause alterations in brain chemistry leading to seizures.

There are some special patients we need to keep in mind. Pregnant females (and i suppose pregnant males, we dont judge) can suffer a condition called eclampsia in which they  have emergently elevated blood pressures which lead to seizures. Alcohol withdrawal, can lead to delirium tremens, and seizures. And certain toxic recreational drug overdoses can cause seizures as well.

So what are some of the causes that may present seizures to us.

Obviously there are seizure disorders, like epilepsy. Trauma, specifically head injuries can cause seizures. Ever see those movies when a guy gets hit on the head and starts convulsing. That’s actually based in some medical science. Hypoxia and stroke can both prevent oxygen from getting to the brain, causing seizures. In addition to oxygen, the brain really likes glucose and salt so when we start to take those away, more seizures. And then there is the concern of infections like meningitis, encephalitis or a brain abscess which can all cause alterations in brain chemistry leading to seizures.

There are some special patients we need to keep in mind. Pregnant females (and i suppose pregnant males, we dont judge) can suffer a condition called eclampsia in which they  have emergently elevated blood pressures which lead to seizures. Alcohol withdrawal, can lead to delirium tremens, and seizures. And certain toxic recreational drug overdoses can cause seizures as well.

The first type of seizure, and the one we all know and recognize right away is the tonic-clonic seizure. These are also known as Grand Mal seizures. They are characterized by a loss of consciousness and loss of muscle tone. They also suffer those extensor muscle spasms which cause the traditional convulsion appearance. Of major concern is the fact they will not be breathing adequately, if at all. And the traditional grand mal seizure will be followed by a postictal phase, which we will talk about.

Partial seizures are a bit different. Known as focal seizures, a Jacksonian march, psychomotor or minor motor seizures these do not present with the typical full body spasms like the Grand Mal seizures. These are usually characterized by unilateral symptoms ranging from simple tingling in the muscle to full contraction to one or several areas of the body. Even with these contractions, there is usually no loss of consciousness, so the patient is fully aware of the situation. Many times these resolve on their own and if they lst less than 5 minutes, we typically do not medicate them.

I also want to mention complex partial seizures here. These are characterized by an alteration in LOC. Patients do not lose consciousness but also may not be aware of what is happening. Typically they look as if they have “zoned out” often string of into space. You can see repetitive lip smacking or swallowing. These patients can move and even walk but the movement is not purposeful. They usually last from 30 seconds to about 2 minutes and when the seizure is done, they can experience a postictal phase with some confusion and no recollection of the period of time they were having the seizure.

Febrile seizures are just that….seizures caused by a febrile…or a fever. The rapid rise in body temp causes the short circuit and the seizure. These are more common in infants and pediatrics and the main treatment is aimed at keeping the patient safe and lowering their temperature. Febrile seizures, while they may be indicative that the child could have another febrile seizure, it is not a sign of a seizure disorder. 

Status epilepticus…this is where things can go bad. Status is considered consecutive seizures with no return to normal. Basically before there postictal phase ends, they seize again. It can also be classified by a seizure lasting more than 5 minutes that isn’t resolved by the usual methods. This is a definite medical emergency. And i want you to think about why. We talked about the tonic clonic seizure that can result in abnormal respirations or apnea. So think about a patient who can’t adequately breathe for 5 minutes. Think about the lack of oxygenation. I also want you to think about the energy being burned by 5 minutes of involuntary muscle contractions. These patients can suffer from acidosis, hypoglycemia, hypercalcemia, muscle damage leading to rhabdomyolysis, and eventually if these things aren’t corrected…death,.

As with everything, documentation is key. One way to help document seizures is by using the COLD mnemonic.

C – Character – What type of seizure occurred?

O – Onset – When did it start? What was the patient doing?

L – Location – Where did the activity start?

D – Duration – How long did the seizure last?

Document these 4 things and you should be covered. Ill give you an example: Patient had  tonic-clonic seizure @ 13:29. Pt was lying in monitored bed, watching television when seizure activity began. Seizure involved both upper and lower extremities and lasted approximately 45 seconds.

Now the answer to the question we all have been asking…what do we do for these patients. Well, as always we keep the basics in mind. Airway, breathing and circulation are our priorities, this is nothing new., We want to get on a non-rebreather mask which we can attach to their face. It becomes difficult to use a bag valve mask on an actively seizing patient but if someone is in status, we may need to perform rapid sequence intubation to paralyze them so that we can insert an airway and breathe for them.

While making sure they are breathing, which is, you know, kind of important, we also want to provide for their safety. They have no control over their spasms and can be striking anything. Smacking against the side rail of the bed, against the floor, wherever they may be. Many facilities have protocols on seizure precautions. Things like padding the side rails of the bed with pillows or blankets. Just check with your facility on what they use as seizure precautions.

We want to stop the seizure and for that we care going to use benzodiazepines. We are going to push IV meds such as Ativan, Valium or phenobarb. I would not recommend using them all at once but we may try each one if one isn’t working. Quick story, a mother brings her 21 year old son in after having 2 seizures in the field lasting about 2 minutes each. He is awake and alert when arriving. 10 minutes after getting to us he has another small seizure that we halt with 2mg of Ativan. We monitor him through his postictal and then we leave the room. About 15 minutes later we here the mother yelling for help and when we enter the room we see the patient on his side, pants around his knees and a syringe like this one sticking out of his rectum. Our first response was….as i’m sure would have been yours, what did you do? I did not know at the time, but apparently, rectal valium can be given to caregivers to be administered in the event of an emergency. This mother, in a panic because no one was in the room, chose to act first rather than call for help. We asked her politely not to do that again as she was in a building filled with medical professionals and i learned something i didn’t know.

Moving on. Once we have stopped the seizure, we want to prevent more from occurring so we might start an infusion of an anticonvulsant like Dilantin, Cerebyx or keppra. any of these can help to prevent seizures and its going to be the docs discretion.

After stopping the seizure we want to provide some metabolic replacement. Very commonly our patient might become hypoglycemic and to correct that, we would typically give an amp of D50. One thing to be aware of, if we have an alcoholic patient, we want to make sure we give an amp of thiamine IV before administering the D50. Chronic alcoholism can cause alterations in the blood brain barrier here and the rapid influx of glucose can actually pass through the weakened barrier too quickly and cause a rebound encephalopathy, also known as Wernicke-Korsakoff syndrome. The easy way to prevent this is just giving that thymine which prevents the rapid absorption of the glucose. it doesn’t prevent it, just slows it to a manageable speed.

So after the seizure has ended, the patient will be in their postictal phase. They will usually be confused and it’s our job to provide for their safety. I want yo to be aware, these patients can be very agitated and even combative, which can manifest in physical violence. Perhaps not to the level see here, but i can’t say I haven’t gotten kicked by a seizure patient or two in my time. Remember, if this patient becomes a little rowdy, they are completely unaware of what they are doing and they also can not control it until the postictal phase passes. Just make sure they don’t hurt themselves or anyone else.

Using our clinical judgment here is important, not just in treating the tonic-clonic seizures, but in recognizing partial and complex partial seizures.

With our more severe seizures, cognition will be impaired both through the seizure as well as for a time after.

And always provide for our patients safety. Use your facility specific seizure precautions. 

A few key points. First thing is to identify the seizure. The tonic-clonic is easy but some of those partial seizures may be harder to identify.

Document using the COLD mnemonic.

Medicate to stop the seizure and then prevent further seizures.

Avoid tunnel vision. ABC’s always. It can be overwhelming when someone is in a full tonic-clonic seizure but remember that this patient cant breathe!

And as always, make sure you are keeping the patient safe, both through the seizure and after.

Once again, thanks guys for joining us. Please check out our other emergency medicine lessons here on NRSNG.com and as always…

HAPPY NURSING!