Seizures

Medical History

[accordion][accordion_item title=”History of Present Illness”]Patient is a [AGE] year old [fe]male with [no] history of seizure disorder presenting with

  • Witnessed
    • [multiple] seizure lasting [DURATION] [ONSET] prior to arrival that have [not] resolved since presenting to the ED. This was witnessed by [WITNESS] who provided part of the history. There was reported movements of [right/left/bilateral] [arms and legs].
  • Unwitnessed
    • possible seizure episode. There were no witnesses.
  • Transport
    • Patient arrived [by EMS] and [MEDICATION] was administered prior to arrival to the ED.
  • Pertinent positives and negatives
    • [no reports of head trauma in recent history.]
    • [no reports of trauma during the seizure.]
    • [no reports of toxic exposures or hazardous ingestions]
    • [+/-] associated loss of consciousness
    • [+/-] associated tongue biting
    • [+/-] associated incontinence
    • [+/-] disorientation after the seizure[s]
  • Known seizure
    • Patient has a known seizure disorder and have been prescribed [AED AND DOSAGE]. Patient is [non]adherent with therapy.
  • Adults
    • [+/-] regular alcohol use.
    • [+/-] illicit drug use.
    • [+/-] normal menstrual period
  • Pediatric
    • [+/-] reports of fever preceding this presentation.
    • [+/-] reports of disruptions in sleep pattern
  • Neonatal
    • [+/-] denies being fed tea, rice water, overly diluter formula, and sources of free water.

[/accordion_item][accordion_item title=”Physical Exam”]Blood pressure was [], pulse was [], respirations were [], temperature was [].
General: The patient appeared well nourished and normally developed.
Head: Atraumatic. No tenderness to palpation.
Eyes: PERRLA.
ENMT: Mucous membranes moist.
Neck: [The patient is brought in by EMS wearing a cervical collar. With cervical spine precautions, the neck exam is:] supple, no cervical spine tenderness or step-off.
Cardiovascular: Regular rate and rhythm
Respiratory: Effort normal and breath sounds normal. No respiratory distress.
Gastrointestinal: Soft and non-distended in all four quadrants.
Musculoskeletal: No gross deformities.
Skin: No rash.
Neurologic: [Alert, attentive and oriented.] [Follows commands appropriately.] [Speech is good with good repetition, comprehension, and naming.] [Pupils are 3+ and equally reactive to light.] [Extraocular movements intact.] [Facial sensation is intact and equal bilaterally.] [Face is symmetric with normal eye closure and smile.] Strength testing of the upper extremities [is 5/5 and equal bilaterally]. Strength testing of the lower extremity [is 5/5 and equal bilaterally]. [Sensation to light touch is intact in the distal extremities.] [Rapid alternating movements are intact.] [There is no abnormal or extraneous movements.] [Gait is normal.] [DTR are intact.][/accordion_item][/accordion]

Medical Decision Making

[accordion][accordion_item title=”Initial Evaluation and Differential”]Upon arrival to the ED, we immediately [placed the patient on a monitor with pulse ox, administered oxygen when needed to maintain good oxygenation,] undressed the patient to facilitate a proper secondary survey and immediately addressed their airway, breathing and circulation to address their physiologic stability. After addressing the ABCs, a history was obtained and we continued with the secondary survey. An capillary blood glucose was obtained which was [#]. Seizure precautions were ordered and implemented.

I have considered the possibility that the patient’s clinical presentation is a life-threatening seizure mimic, which includes syncope, cardiac dysrhythmia, or a movement disorder. However, I have been able to exclude them from consideration as it is inconsistent with my history and physical exam.[/accordion_item][accordion_item title=”Status Epilepticus”]Initial Intervention

  • I made the diagnosis of status epilepticus.
  • IV access was established by [the nursing staff] and [X] of IV lorazepam was administered.
    • 0.1mg/kg
    • 2mg
  • [X] was administered before IV access was obtained with some difficulty.
    • 0.2mg/kg | 2mg of intranasal lorazpam
    • 0.2mg/kg of IM/intranasal midazolam
    • 10mg of IM midazolam
    • Rectal diazepam

Second line intervention

  • The seizure did not terminate with the above medication after [X] minutes, so a repeat dose was administered.
  • After the above treatment, I administered an infusion of [X]
    • IV Phenytoin at 20mg/kg at 50mg/min
    • IV fosphenytoin 20PE/kg at 150mg/min
    • IV Levetiracetam 20mg/kg at 2-5mg/kg/min
    • IV Valproic acid 20mg/kg at 40mg/min

Intubation and third line treatment

  • Due to my concern to the inability of the patient to protect their airway, I made the decision to secure their airway by performing endotracheal intubation.
  • Rapid sequence intubation was conducted by me under the direct supervision of the attending physician. After adequate preoxygenation and induction with [20 milligrams of IV etomidate] and neuromuscular blockade with [70 mg of rocuronium,] and a [7.5] endotracheal tube was passed through the vocal cords in one attempt under my direct vision with [a Mac 4 blade, grade 2 view]. Tube placement was verified by bilateral breath sounds, endotracheal tube fogging, and colormetric CO2 color change. Patient was placed on continuous waveform capnography. Initial ventillator settings of [AC 500, 12, 100%, 5 PEEP]. The patient was unable to consent directly due to critical clinical condition, and consent was implied. [2 mg of Ativan] was given for post intubation
  • Because there was not an adequate response to the above treatment. I initiated an infusion of
    • 0.2mg/kg of IV midazolam bolused over 5 minutes followed with a drip that was titrated to clinical response
    • 1-2mg/kg IV propofol bolused over 5 min followed with a drip that was titrated to clinical response
    • 20mg/IV phenobarbital bolused over 5 minutes followed by a drip that was titrated to clinical response
  • Due to my concern that the patient’s clinical presentation could be secondary to [X]
    • eclampsia, I initiated an infusion of 4g of IV magnesium over 20 minutes.
    • isoniazid induced seizures, I administered 5g of IV pyridoxine pushed slowly.
    • pyridoxine induced epilepsy, I administered 100mg of IV pyridoxine.
  • Resolution
    • The patient’s seizure activity terminated with the above treatment. I noted that the patient withdrew to painful stimuli after cessation of seizure activity.

[/accordion_item][accordion_item title=”Diagnostics”]Known Seizure Disorder

  • I made the decision to check the patient’s [AED] level, as low or toxic drug levels can cause increased seizures.
    • The patient’s [AED] level was subtherapeutic, and was subsequently supplemented intravenously/orally.
    • The patient’s [AED] level was therapeutic, and no supplemental doses were given.
  • Unfortunately, the patient’s [AED] is not one with easily checked drug levels.
    • But based on the patient’s history of non-compliance, a supplemental oral dose of the medication was administered.
    • But based on the patient’s history of compliance, a supplemental oral dose was not administered.

Differential Exclusions

  • Patient’s symptoms is not consistent with a gross electrolyte disturbance,  as they are otherwise healthy and did not have a positive history for an acute illness, vomiting, or diarrhea.
  • Patient’s symptoms is not consistent with hypoglycemia, as they had a normal Accuchek at presentation.
  • Patient’s symptoms is not consistent with a central nervous system infection, brain tumor, intracranial bleed, or ischemic stroke, as there are no focal neurological abnormalities and the patient is at their neurological baseline.
  • Patient’s symptoms is not consistent with toxin mediated process, as there are no reported history of ingestion.
  • Patient’s symptoms is not consistent with withdrawal, as there are no report of benzodiazepine or alcohol abuse and the patient did not present with other symptoms of withdrawal such as agitation or tremors.
  • Patient’s symptoms is not consistent with hypoxia, as they have a normal pulse oximetry on room air.
  • Patient’s symptoms are not consistent with eclampsia, as they had a recent normal menstrual period.

Chemistry Panel

  • Due to my inability to exclude the diagnosis of a electrolyte disturbances from my differential diagnosis with my history and physical exam alone. I decided to obtain a chemistry panel which, demonstrated that the patient’s glucose, sodium, calcium and magnesium levels were all within normal limits.

CT Head

  • Due to my inability to exclude the diagnosis of a brain tumor, intracranial bleed, or ischemic stroke, I decided to obtain a CT scan of the head, which demonstrated no acute intracranial process such as hemorrhage, infarction, or infection.

No CT

  • Because the patient had a self-limited seizure who returned to baseline mental status, has a normal neurologic examination, have no signs of increased intracranial pressure, and have no suspicion of trauma, I have decided to not perform neuroimaging. I did recommend that the patient be seen by a neurologist in the next 1-2 days to undergo further evaluation that may include timely outpatient MRI and EEG.

Lumbar Puncture

  • Due to my inability to exclude the diagnosis of a central nervous system infection, the patient require further workup with a lumbar puncture.
  • I have discussed the lumbar puncture with the patient. I have informed the patient regarding the risks, benefits, side effects and expected outcomes and likelihood of achieving the goals for the procedure. I have also discussed alternatives of the procedure, the risks and benefits of the alternatives, and the possible results of not receiving this treatment. After discussion, the patient has agreed to undergo the procedure.
  • Universal precautions were taken. The area was prepped with povidone and the skin was locally anesthetized with 1% lidocaine. A spinal needle with stylette was inserted between L4 and L5 spinous processes. CSF was collected and sent for laboratory analysis, and demonstrated no abnormalities consistent with infection. The patient is instructed to remain for the next hour.

No Lumbar Puncture

  • Because the patient did not have signs and symptoms of meningitis or encephalitis, is fully immunized, and is well-appearing, I have decided to not perform a lumbar puncture.

Serum drug screen

  • Due to my inability to exclude the diagnosis of a toxic ingestion from my differential diagnosis with my history and physical alone, I decided to obtain a serum drug screen, which was negative for toxic levels of acetaminophen, salicylate, and tricyclic acid.

Pregnancy test

  • Due to my inability to exclude the diagnosis of eclampsia from my differential diagnosis with my history and physical alone, I decided to obtain a pregnancy test, which was negative.

Urinalysis

  • Due to my inability to exclude the diagnosis of a urinary tract infection as a contributing factor to the patient’s symptoms, I decided to obtain a urinalysis, which result was not specific for a urinary tract infection.

Creatine protein kinase

  • Due to my inability to exclude the diagnosis of rhabdomyolysis secondary to prolonged seizure, I obtained a creatine protein kinase, which result was not specific for muscle breakdown.

EEG

  • Due to my inability to exclude the diagnosis of non-convulsive status epilepticus, I decided to obtain an EEG, which result is pending.

Decisions

  • These decisions are supported by known guidelines published by the American Academy of Neurology.
  • After consultation with a neurologist, I have decided to [X].

[/accordion_item][accordion_item title=”Disposition”]

  • Discharge
    • Because the patient has a normal neurological examination. They can be discharged with outpatient followup with a neurologist. I have reassured the patient[‘s family] that a single seizure does not necessarily mean that the patient will have a seizure disorder. I have given seizure precautions, including advisement to not swim or take baths alone, and to to avoid driving until they could see a neurologist. I have reported the patient’s seizure to the state as required by law.
  • Admit
    • Because the patient [X], they require admission for further observation and evaluation by an inpatient physician and neurologist.
      • home conditions and likelihood of reliable follow-up are inadequate
      • have failed outpatient treatment
      • comorbidities
      • have not returned to baseline neurological status
      • young age
      • focal neurological findings.
      • inability to exclude the diagnosis of central nervous system infection
      • concern for recurrent seizure.
      • prolonged seizure

[/accordion_item][/accordion]