Ep 132 Emergency Approach to Resolved Seizures

In this Episode 132 Emergency Approach to Resolved Seizures, Dr. Paul Koblic and Dr. Aylin Reid discuss with Anton the nuances in history taking, physical examination, workup and management of the patient who presents to the ED after suffering a seizure. They answer questions such as: What is the essential list of immediate life threats with specific antidotes that we must know for the ED patient with a seizure? What are the key elements for distinguishing a true seizure from syncope? From Psychogenic Non-Epileptic Seizure (PNES)? From TIA? From migraine? How do you distinguish Todd's Paralysis from TIA or stroke? What are indications for serum lactate and troponin in patients who present with a seizure? Do all patients with first time unprovoked seizures require anti-seizure medication in the ED? What is the preferred anti-seizure medication and route for ED loading for the patient with a first time seizure? Which patients who present with seizure require a CT head in the ED? What are indications and ideal timing for EEG for patient who present to the ED with seizure? and many more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Winny Li & Lorraine Lau, edited by Anton Helman November, 2019 Cite this podcast as: Helman, A. Reid, A. Koblic, P. Ep 132 Emergency Approach to Seizures and Seizure Management. Emergency Medicine Cases. November, 2019. https://emergencymedicinecases.com/approach-seizures-management. Accessed [date] Go to part 2 of this 2-part podcast on seizures General approach to the patient with a presumed resolved seizure * ABCDEFG (ABC’s and Don’t Ever Forget the Glucose) * Establish IV access (for medication delivery if recurrent seizure in the ED) * Distinguish between seizure vs seizure mimics * Distinguish between first seizure vs recurrent seizure * Categorize the seizure * Identify the underlying cause of seizure * Assess for complications of seizure * Assess anti-seizure drug levels * Disposition and discharge instructions Step 3: Distinguish between a seizure and seizure mimics We attribute cardiac syncope to seizure in about 10-20% of patients who we label as having a seizure. Elements that are highly suggestive of true seizure activity include (from highest LR to lowest): * Lateral tongue-biting * Lateral head rotation * Unusual posturing * Urinary incontinence * Blue skin colour observed by bystanders * Limb jerking * Prodromal trembling, hallucinations, pre-occupation or deja-vu * Amnesia for behaviors surrounding event * Postictal phase Factors that decrease the likelihood of true seizures * Presyncope before LOC * LOC with prolonged standing, sitting * Prodromal diaphoresis, vertigo, nausea, chest pain, feeling of warmth, palpitations or dyspnea   Pearl: Lateral tongue biting has a specificity of 100% for the diagnosis of generalized tonic-clonic seizures in patients who present with a transient loss of consciousness. Distinguishing seizure from syncope All patients who present with a presumed seizure should have an ECG done to assess for causes of cardiac syncope. Distinguishing seizure from psychogenic non-epileptiform seizures (PNES) PNES, formerly "pseudoseizures”, are not due to abnormal electrical activity in the brain. When in doubt, assume true seizure as it can be extremely difficult to distinguish PNES from epileptic seizures in the ED.