Hi, we’re gonna be talking about
patients who present with seizures
and how to manage them in
the Emergency Department.
So what is a seizure?
A seizure is when there is
excessive abnormal neuron activity.
Seizures can be divided
into three large groups.
A person can have a partial seizure which
is also known as a focal onset seizure,
a generalized seizure or a
seizure of unknown onset.
Just some definitions
before we get started.
So the ictal period is the time when
the actual seizure is occurring.
So this is the time that the patient is
having or undergoing that seizure activity.
The post-ictal period is a period of
altered mental status following a seizure.
A post-ictal period can range in time
anywhere from about 10 or 15 minutes
up to hours or
possibly even a day.
Status epilepticus is when a patient has
seizure activity for more than 5 minutes,
or a patient has recurrent
So they have another seizure without
a return to baseline mental status.
The reason that it’s important
to mention status epilepticus
is because for those patients,
you wanna make sure that you
treat the seizures aggressively.
Because as time goes on and
as the patient has consistent
or continuous seizure activity,
that can lead to an increased
metabolic demand for the brain
and in turn,
can eventually lead to brain damage.
So we wanna make sure that
we’re paying attention
to how long a patient
is seizing for
and whether or not they're having
another seizure before they turn back
to their neurologic baseline,
because in those patients,
you wanna make sure
that they’re treated
Epilepsy is an
So that’s a seizure due
to no provoking factor.
Sometimes it can be due to underlying
structural issues in the brain.
Focal onset seizures can
be further classified
based on the patients
level of awareness.
The earliest detectable sign of
behavior during a seizure or both.
These two levels of classifications are
not higher article or mutually exclusive.
These terms can be added or excluded
based on the information available
about each specific patient.
Within the focal onset category,
seizures can be classified as focal aware,
or focal impaired
These terms correspond to the old
terms, simple partial
and complex partial seizures.
Additionally, seizures can be
classified as a focal onset seizure
with any of several motor or
non-motor signs and behaviors.
Some motor types include automatism,
when patients perform coordinated,
repetitive actions such as suckling.
Other motor types are atonic,
tonic, clonic and myoclonic.
Some non-motor types include behavior
arrest, cognitive and emotional.
The category of
generalized onset seizure
is very similar to that of the
previously used classification of 1981.
It does not use level of awareness
as a distinguishing factor,
because awareness is usually
impaired in all generalized seizures.
Instead, these seizures are only
classified in the generalized onset motor
or non-motor seizures,
based on the types of movements performed.
The classic tonic-clonic seizure
previously called grand mal,
is characterized by alternating episodes
of generalized stiffening of the body,
and sustained rhythmic
Generalized myoclonic seizures
can occur in isolation
in combination with
tonic or clonic activity,
with both or atonic activity.
Atonic seizures are usually
characterized by a lost of leg tone.
Because all generalized seizures
initially involve losing leg tone,
can be distinguish
because the patient usually falls on their
buttocks, or into their knees or face.
All other generalized seizures usually
make the patient fall backward.
includes several varieties
of absent seizures.
And absent seizure is
characterized by a sudden onset
A blank stare, impossibly a brief
upward deviation of the eyes.
An EEG maybe required
between atypical and
typical absent seizures.
Finally, seizures of unknown
onset can be motor or non-motor.
The term unknown onset is usually used
in cases where the beginning of a seizure
was obscured or not
witness by anyone.
These seizures are
when the patient experiences another
seizure while under observation.
Who primarily gets seizures or
presents to the hospital with seizures?
There's a bimodal
So infants and young kids primarily
will have febrile seizures.
These are seizures that are related
to generally higher temperatures.
For the most part,
they’re benign in nature
and often times do not recur,
although sometimes they do.
The other age of range
are older people.
So patients who are greater
than 75 years of age.
So you wanna think
about the seizures
or you know who presents with
them are the young and the old.
There’s definitely a lot of
people in the middle as well
but those are kind of
the biggest groups.
Recurring seizures occur in about
half of patients with epilepsy.
So those patients may
recurrently have these episodes.