January 2015 Clinical Decision Making Volume 17, Number 1 Authors In Seizures And Felipe Teran, MD Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Faculty, Emergency Department, Clínica Status Epilepticus Alemana, Santiago, Chile Katrina Harper-Kirksey, MD Abstract Anesthesia Critical Care Fellow, Department of Anesthesia, Stanford Hospital and Clinics, Stanford, CA Andy Jagoda, MD, FACEP Seizures and status epilepticus are frequent neurologic emergen- Professor and Chair, Department of Emergency Medicine, Icahn cies in the emergency department, accounting for 1% of all emer- School of Medicine at Mount Sinai, New York, NY; Medical Director, Mount Sinai Hospital, New York, NY gency department visits. The management of this time-sensitive and potentially life-threatening condition is challenging for both Peer Reviewers prehospital providers and emergency clinicians. The approach to J. Stephen Huff, MD Professor of Emergency Medicine and Neurology, University of seizing patients begins with differentiating seizure activity from Virginia, Charlottesville, VA mimics and follows with identifying potential secondary etiolo- Jason McMullan, MD gies, such as alcohol-related seizures. The approach to the patient Assistant Professor, Department of Emergency Medicine, University of in status epilepticus and the patient with nonconvulsive status Cincinnati, Cincinnati, OH epilepticus constitutes a special clinical challenge. This review CME Objectives summarizes the best available evidence and recommendations Upon completion of this article, you should be able to: regarding diagnosis and resuscitation of the seizing patient in the 1. Describe the diagnostic approach to patients who have recovered from a seizure and patients in status epilepticus. emergency setting. 2. Recognize and treat patients with alcohol withdrawal seizures. 3. Choose appropriate pharmacologic therapy for seizure states. Prior to beginning this activity, see “Physician CME Information” on the back page. Editor-In-Chief Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, Stephen H. Thomas, MD, MPH Research Editors Andy Jagoda, MD, FACEP Professor and Chair, Department FACEP George Kaiser Family Foundation Michael Guthrie, MD Professor and Chair, Department of of Emergency Medicine, Carolinas Professor and Chair, Department of Professor & Chair, Department of Emergency Medicine Residency, Emergency Medicine, Icahn School Medical Center, University of North Emergency Medicine, Pennsylvania Emergency Medicine, University of Icahn School of Medicine at Mount of Medicine at Mount Sinai, Medical Carolina School of Medicine, Chapel Hospital, Perelman School of Oklahoma School of Community Sinai, New York, NY Director, Mount Sinai Hospital, New Hill, NC Medicine, University of Pennsylvania, Medicine, Tulsa, OK Philadelphia, PA Federica Stella, MD York, NY Steven A. Godwin, MD, FACEP David M. Walker, MD, FACEP, FAAP Emergency Medicine Residency, Professor and Chair, Department Michael S. Radeos, MD, MPH Director, Pediatric Emergency Giovani e Paolo Hospital in Venice, Associate Editor-In-Chief of Emergency Medicine, Assistant Assistant Professor of Emergency Services, Division Chief, Pediatric University of Padua, Italy Kaushal Shah, MD, FACEP Dean, Simulation Education, Medicine, Weill Medical College Emergency Medicine, Elmhurst Associate Professor, Department of University of Florida COM- of Cornell University, New York; Hospital Center, New York, NY International Editors Emergency Medicine, Icahn School Jacksonville, Jacksonville, FL Research Director, Department of of Medicine at Mount Sinai, New Emergency Medicine, New York Ron M. Walls, MD Peter Cameron, MD Gregory L. Henry, MD, FACEP York, NY Hospital Queens, Flushing, NY Professor and Chair, Department of Academic Director, The Alfred Clinical Professor, Department of Emergency Medicine, Brigham and Emergency and Trauma Centre, Editorial Board Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Women's Hospital, Harvard Medical Monash University, Melbourne, of Michigan Medical School; CEO, Vice-Chair, Emergency Medicine, School, Boston, MA Australia William J. Brady, MD Medical Practice Risk Assessment, Massachusetts General Hospital, Professor of Emergency Medicine Inc., Ann Arbor, MI Boston, MA Critical Care Editors Giorgio Carbone, MD and Medicine, Chair, Medical John M. Howell, MD, FACEP Robert L. Rogers, MD, FACEP, Chief, Department of Emergency Emergency Response Committee, William A. Knight, IV, MD, FACEP Medicine Ospedale Gradenigo, Clinical Professor of Emergency FAAEM, FACP Medical Director, Emergency Assistant Professor of Emergency Torino, Italy Management, University of Virginia Medicine, George Washington Assistant Professor of Emergency Medicine and Neurosurgery, Medical Medical Center, Charlottesville, VA University, Washington, DC; Director Medicine, The University of Director, EM Midlevel Provider Amin Antoine Kazzi, MD, FAAEM of Academic Affairs, Best Practices, Maryland School of Medicine, Program, Associate Medical Director, Associate Professor and Vice Chair, Mark Clark, MD Inc, Inova Fairfax Hospital, Falls Baltimore, MD Neuroscience ICU, University of Department of Emergency Medicine, Assistant Professor of Emergency Church, VA University of California, Irvine; Alfred Sacchetti, MD, FACEP Cincinnati, Cincinnati, OH Medicine, Program Director, Shkelzen Hoxhaj, MD, MPH, MBA Assistant Clinical Professor, American University, Beirut, Lebanon Emergency Medicine Residency, Scott D. Weingart, MD, FCCM Chief of Emergency Medicine, Baylor Department of Emergency Medicine, Mount Sinai Saint Luke's, Mount Associate Professor of Emergency Hugo Peralta, MD College of Medicine, Houston, TX Thomas Jefferson University, Sinai Roosevelt, New York, NY Medicine, Director, Division of Chair of Emergency Services, Philadelphia, PA Eric Legome, MD ED Critical Care, Icahn School of Hospital Italiano, Buenos Aires, Peter DeBlieux, MD Chief of Emergency Medicine, Robert Schiller, MD Medicine at Mount Sinai, New Argentina Professor of Clinical Medicine, King’s County Hospital; Professor of Chair, Department of Family Medicine, York, NY Dhanadol Rojanasarntikul, MD Interim Public Hospital Director Clinical Emergency Medicine, SUNY Beth Israel Medical Center; Senior Attending Physician, Emergency of Emergency Medicine Services, Downstate College of Medicine, Faculty, Family Medicine and Senior Research Editors Medicine, King Chulalongkorn Louisiana State University Health Brooklyn, NY Community Health, Icahn School of James Damilini, PharmD, BCPS Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Medicine at Mount Sinai, New York, NY Thailand; Faculty of Medicine, Keith A. Marill, MD Clinical Pharmacist, Emergency Nicholas Genes, MD, PhD Research Faculty, Department of Scott Silvers, MD, FACEP Room, St. Joseph’s Hospital and Chulalongkorn University, Thailand Assistant Professor, Department of Emergency Medicine, University Chair, Department of Emergency Medical Center, Phoenix, AZ Suzanne Y.G. Peeters, MD Emergency Medicine, Icahn School of Pittsburgh Medical Center, Medicine, Mayo Clinic, Jacksonville, FL Joseph D. Toscano, MD Emergency Medicine Residency of Medicine at Mount Sinai, New Pittsburgh, PA Chairman, Department of Emergency Director, Haga Teaching Hospital, York, NY Corey M. Slovis, MD, FACP, FACEP The Hague, The Netherlands Professor and Chair, Department Medicine, San Ramon Regional of Emergency Medicine, Vanderbilt Medical Center, San Ramon, CA University Medical Center, Nashville, TN Case Presentations Seizures may be classified according to whether they are caused by an underlying process (pro- A 19-year-old man with no serious medical history pres- voked) or not (unprovoked). Acute central nervous ents to the ED after reports of seizure-like activity. Ac- system (CNS) insults, toxins, or acute metabolic cording to the patient’s mother, he was lying on the sofa derangements can trigger provoked seizures. when he became unresponsive and began having tonic- Epilepsy is a condition of recurrent unpro- clonic activity in all extremities. The episode lasted 30 voked seizures. For example, a patient who suf- seconds, included urine incontinence, and was followed fers head trauma might have an acute seizure but by a 20-minute period of confusion. He said there have would not be considered to have epilepsy unless been no previous episodes; however, the mother reports there are recurrent unprovoked events as a result of that he once had a febrile seizure as a child. The patient the brain injury. denies drug use and infectious symptoms. On arrival, the The term ictus refers to the period during which patient is awake and completely responsive, with a normal a seizure occurs. Postictal period refers to the interval neurologic examination. You wonder if this patient needs immediately following the seizure but before the neuroimaging and whether he should be admitted to the patient returns to baseline mental status. An aura is hospital for a workup… a focal seizure and is defined by the area of the brain You receive a notification from EMS that they are where the seizure originates (eg, a patient with a bringing in a 22-year-old man who was “found down" temporal lobe focus may have a déjà vu experience and has been having tonic-clonic seizures on and off, before the focal event spreads into a generalized without return to baseline, for at least 30 minutes. EMS tonic-clonic seizure). gives an ETA of 10 minutes. The paramedics have been Seizures