Epileptic Seizure; Causes, Symptoms, Diagnosis, Treatment

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Epileptic seizure also known as an epileptic fit is a brief episode of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. The outward effect can vary from uncontrolled jerking movement (tonic-clonic seizure) to as subtle as a momentary loss of awareness (absence seizure). Diseases of the brain characterized by an enduring predisposition to generate epileptic seizures are collectively called epilepsy

Differences between seizure & Epilepsy

Seizure
Pathologic neuronal activation leading to abnormal function
Epilepsy
Recurrent unprovoked seizures

Types

Cause

  • Primary: Unprovoked
  • Secondary: Provoked, caused by trauma, illness, intoxication, metabolic disturbances, etc.

Effect on mentation

  • Generalized: involvement of both hemispheres with associated loss of consciousness (tonic-clonic, absence, atonic, myoclonic)
  • Focal: Involving single hemisphere with the preserved level of consciousness.

Status epilepticus

  • Witnessed convulsions lasting >5min
  • Recurrent seizure without recovery from a postictal period

Furthers classification of seizures

  • Tonic-clonic (or grand mal) seizures – These are the most noticeable. When you have this type, your body stiffens, jerks, and shakes, and you lose consciousness. Sometimes you lose control of your bladder or bowels. They usually last 1 to 3 minutes. That can lead to breathing problems or make you bite your tongue or cheek
  • Clonic seizures – Your muscles have spasms, which often make your face, neck, and arm muscles jerk rhythmically. They may last several minutes.
  • Tonic seizures – The muscles in your arms, legs, or trunk tense up. These usually last less than 20 seconds and often happen when you’re asleep. But if you’re standing up at the time, you can lose your balance and fall. These are more common in people who have a type of epilepsy known as Lennox-Gastaut syndrome, though people with other types can have them, too.
  • Atonic seizures  – Your muscles suddenly go limp, and your head may lean forward. If you’re holding something, you might drop it, and if you’re standing, you might fall. These usually last less than 15 seconds, but some people have several in a row. Because of the risk of falling, people who tend to have atonic seizures may need to wear something like a helmet to protect their heads.
  • Myoclonic seizures – Your muscles suddenly jerk as if you’ve been shocked. They may start in the same part of the brain as an atonic seizure, and some people have both myoclonic and atonic seizures.
  • Absence (or petit mal) seizures – You seem disconnected from others around you and don’t respond to them. You may stare blankly into space, and your eyes might roll back in your head. They usually last only a few seconds, and you may not remember having one. They’re most common in children under 14.

Focal Seizures can ber break these into three groups

  • Simple focal seizures – They change how your senses read the world around you: They can make you smell or taste something strange, and may make your fingers, arms, or legs twitch. You also might see flashes of light or feel dizzy. You’re not likely to lose consciousness, but you might feel sweaty or nauseated.
  • Complex focal seizures – These usually happen in the part of your brain that controls emotion and memory. You may lose consciousness but still look like you’re awake, or you may do things like gag, smack your lips, laugh, or cry. It may take several minutes for someone who’s having a complex focal seizure to come out of it.
  • Secondary generalized seizures – These start in one part of your brain and spread to the nerve cells on both sides. They can cause some of the same physical symptoms as a generalized seizure, like convulsions or muscle slackness.

Causes 

Different causes of seizures are common in certain age groups.

  • Stroke
  • Cancer
  • Brain tumors
  • Head injuries
  • Electrolyte imbalance
  • Very low blood sugar
  • Repetitive sounds or flashing lights, as in video games
  • Some medications, like antipsychotics and some asthma drugs
  • Withdrawal from some medications, like Xanax, narcotics, or alcohol
  • Use of narcotics, such as cocaine and heroin
  • Brain infections, like meningitis
  • Seizures in babies are most commonly caused by hypoxic ischemic encephalopathy, central nervous system (CNS) infections, trauma, congenital CNS abnormalities, and metabolic disorders.
  • The most frequent cause of seizures in children is febrile seizures, which happen in 2–5% of children between the ages of six months and five years.
  • During childhood, well-defined epilepsy syndromes are generally seen.
  • In adolescence and young adulthood, non-compliance with the medication regimen and sleep deprivation are potential triggers.
  • Pregnancy and labor and childbirth, and the post-partum, or post-natal period (after birth) can be at-risk times, especially if there are certain complications like pre-eclampsia.
  • During adulthood, the likely causes are alcohol-related, strokes, trauma, CNS infections, and brain tumors.
  • In older adults, cerebrovascular disease is a very common cause. Other causes are CNS tumors, head trauma, and other degenerative diseases that are common in the older age group, such as dementia.

Causes of Seizures

Symptoms

For generalized onset seizures

  • Motor symptoms may include sustained rhythmical jerking movements (clonic), muscles becoming weak or limp (atonic), muscles becoming tense or rigid (tonic), brief muscle twitching (myoclonus), or epileptic spasms (body flexes and extends repeatedly).
  • Non-motor symptoms are usually called absence seizures. These can be typical or atypical absence seizures (staring spells). Absence seizures can also have brief twitches (myoclonus) that can affect a specific part of the body or just the eyelids.

For focal onset seizures

  • Motor symptoms –  may also include jerking (clonic), muscles becoming limp or weak (atonic), tense or rigid muscles (tonic), brief muscle twitching (myoclonus), or epileptic spasms. There may also be automatisms or repeated automatic movements, like clapping or rubbing of hands, lip-smacking or chewing, or running.
  • Non-motor symptoms – Examples of symptoms that don’t affect movement could be changes in sensation, emotions, thinking or cognition, autonomic functions (such as gastrointestinal sensations, waves of heat or cold, goosebumps, heart racing, etc.), or lack of movement (called behavior arrest).

For unknown onset seizures

  • Motor seizures  – are described as either tonic-clonic or epileptic spasms.
  • Non-motor seizures –  usually include a behavior arrest. This means that movement stops – the person may just stare and not make any other movements.

Diagnosis

Physical Exam

VS:T 98.4 HR 67 RR 17 BP 116/67 O2 98% RA
Gen:Well-appearing, no acute distress
HEENT:PERRL, MMM, no lesions, discs sharp b/l
CV:RRR, normal S1/S2, no M/R/G
Lungs:CTAB, no crackles/wheezing, no focal consolidation
Abd:+BS, soft, NT/ND, no hepatosplenomegaly
GU:Testes descended b/l, no masses, non-tender
Ext:Warm, well-perfused, no rashes/ecchymoses
Neuro:AAOx4, CN II-XII intact, OS 20/40 OD 20/70, normal visual fields to confrontation, no dysmetria/dysdiadochokinesia, normal gait

Treatment

Management of Seizures

Medications for Treatment of Seizures

MEDICATIONDOSE (ADULT)DOSE (PEDS)COMMENT
1ST LINE
Lorazepam4mg IV<13kg: 0.1mg/kg (max 2mg)
13-39kg: 2mg>39kg: 4mg
Repeat in 10min
Midazolam10mg IM0.2mg/kg IM (max 5mg)Repeat in 10min
Midazolam10mg buccal0.5mg/kg buccal (max 5mg)Repeat in 10min
2ND LINE
Fosphenytoin20mg PE/kg IV
Phenytoin20mg/kg IVMay cause hypotension
3RD LINE
Midazolam0.05-2mg/kg/hr
Propofol1-2mg/kg bolus then 20-200mcg/kg/min
Pentobarbital5-15mg/kg bolus then 0.5-5mg/kg/hr
SPECIAL CONDITIONS
Glucose50mL D50/WHypoglycemia
MgSO46g IV over 15minEclampsia (20wks gestation to 6wks post-partum)
Pyridoxine0.5g/min until seizures stop, max 5gINH ingestion
3% saline100-200mL over 1-2hConfirmed hyponatremia

References

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