• Witnessed? Determine whether patient experienced tonic-clonic activity while unconscious: Consider Seizure.
  • Post-ictal state 20-30 minutes of confusion once regained consciousness: Consider Seizure.
  • Tongue biting and/or diffusely sore muscles, generalized weakness: Consider seizure.

Work up:

  • Seizure protocol initiated.
  • CT of the head without contrast – r/o intracranial hemorrhage as etiology
  • Order MRI of brain with and without contrast
    1. Tumor – seen on MRI
    2. Posterior Reversible Encephalopathy Syndrome (PRES): signal abnormalities predominantly in the parietal occipital lobe (areas of edema), consistent with PRES – Tx the underlying cause (ex: uncontrolled HTN)
      1. In 2-3 days, repeat MRI to be certain these hyperintense lesions resolve, which is typical of PRES.
      2. Sx: headache, confusion, seizures, and visual loss (symptoms tend to resolve after a period of time, although visual changes sometimes remain) Focal neuro deficits are unlikely for PRES (this CVA/TIA instead).
      3. Causes: malignant hypertension, eclampsia.
  • Order EEG: rule out any structural process or focal processes that could provoke seizures
  • Neurology consult (ex: Thomas C Perry, MD, Guangbin Xia, MD)
  • Order seizure precautions and fall precautions.
  • Keep the patient NPO and get speech therapy evaluation.
  • Ativan 1 mg PRN for seizures lasting more than 5 minutes.
  • Order TSH: thyroid disease may potentiate seizure activity (and may be etiology of HTN) Order Prolactin level and urine drug screen.
  • Tx: Divalproex (Depakote), Levetiracetam (Keppra 500mg IV bid), Lamictal (Lamotrigene)
    • ICU with seizures: Control intractable seizures.
      • Ativan PRN
      • Consider Propofol vs Versed
        • Propofol can cause a decrease in BP, so if patient has hypotension too, choose Versed.
      • Fosphenytoin (Cerebyx) loading dose
        • Ordered Fosphenytoin 1,800mg PE in NS 50ml IV.
          • Dose: 18mg PE/kg IV X 1 dose.
      • Phenytoin (Dilantin) 100mg IV q8hr
      • Vimpat (Lacosamide) 200mg in NS 100ml IV
        • Dose: 200mg IV q12hrs
    • Example: Tonic-clonic seizure-like activity, new onset following cardiac arrest with ROSC: Patient has received multiple doses of Ativan IV. Started Versed drip for sedation and for anti-epileptic properties. Spoke with pharmacy: Started Fosphenytoin one time loading dose. Started Phenytoin IV.
    • Prevent seizures: Keppra 500mg IV q12 hours.
  • If patient does not have any improvement of cognition to baseline within 24 hours, advise cerebrospinal fluid analysis (lumbar puncture).

Example A&P – Seizures:

Ordered CT head without contrast. Keep patient NPO. Continue Keppra 500mg IV bid. Place on seizure precautions and fall precautions. Neuro checks q2hrs. Neurology is consulted. Plan to administer additional Ativan if the patient experiences a repeated seizure. If the patient starts to require higher doses of benzodiazepines or develops a seizure that is refractory to medications, the patient may require intubation and sedation with propofol. The ICU team would need to be consulted at that time. Alcohol cessation encouraged as it would likely mitigate seizures

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