From the Guidelines
In-hospital seizures are primarily caused by acute symptomatic conditions, such as metabolic disturbances, drug toxicity or withdrawal, central nervous system infections, acute stroke, traumatic brain injury, and brain tumors, as well as exacerbations of pre-existing epilepsy. These causes can be broadly classified into provoked and unprovoked seizures, with provoked seizures being those that occur at the time of or within 7 days of an acute neurologic, systemic, metabolic, or toxic insult, as defined in a study published in the Annals of Emergency Medicine 1.
Common Causes of In-Hospital Seizures
- Metabolic disturbances, including hyponatremia, hypoglycemia, hypocalcemia, and uremia
- Drug toxicity or withdrawal, particularly from benzodiazepines, alcohol, and antiepileptic medications
- Central nervous system infections, such as meningitis and encephalitis
- Acute stroke and traumatic brain injury
- Brain tumors
- Medication-related seizures, which can occur with certain antibiotics, antipsychotics, antidepressants, and contrast agents
- Systemic conditions, including high fever, sepsis, and severe organ dysfunction affecting the liver or kidneys
Management of In-Hospital Seizures
Identifying and treating the underlying cause is essential for effective management of in-hospital seizures. According to the study published in the Annals of Emergency Medicine 1, classifying seizures as provoked or unprovoked can help guide management. For example, provoked seizures may require treatment of the underlying cause, such as correcting metabolic disturbances or discontinuing offending medications. In contrast, unprovoked seizures may require antiepileptic medication to prevent recurrence.
Treatment of Status Epilepticus
Status epilepticus, a prolonged seizure lasting more than 5 minutes or recurrent seizures without recovery between episodes, represents a medical emergency requiring prompt treatment with benzodiazepines, followed by antiepileptic drugs if seizures persist. The study published in the Annals of Emergency Medicine 1 provides a framework for evaluating and managing adult patients presenting to the emergency department with seizures, which can be applied to the in-hospital setting.
From the Research
Causes of In-Hospital Seizures
- Seizures can be caused by a variety of factors, including toxic or metabolic diseases, organ failure, electrolyte imbalance, medication, and medication withdrawal 2, 3.
- Reactive seizures, which occur in response to extracranial disease, can be caused by toxins that alter the balance of excitation and inhibition in the nervous system or interfere with energy metabolism 2.
- Metabolic diseases, such as those that interfere with energy metabolism, change osmolality, or produce endogenous toxins, can also cause seizures 2.
- Substance abuse can also lead to seizures, either through direct or indirect mechanisms, such as intoxication or withdrawal 4.
- Acute symptomatic seizures, which are seizures that occur in response to a potentially life-threatening underlying condition, can be caused by factors such as alcohol withdrawal, hemorrhagic stroke, and other medical conditions 5.
- Certain medications, such as levetiracetam and pain medications, can also provoke seizures in susceptible individuals, particularly in those with underlying medical conditions such as central diabetes insipidus 6.
Common Causes of In-Hospital Seizures
- Alcohol withdrawal 3, 5
- Electrolyte imbalance 3
- Medication and medication withdrawal 3
- Organ failure 3
- Substance abuse 4
- Hyponatremia 6
- Hemorrhagic stroke 5
Importance of Identifying Underlying Causes
- Identifying the underlying cause of a seizure is crucial for effective treatment and management 2, 3, 5.
- Treatment of seizures in medically ill patients should be aimed at correcting the underlying cause, with appropriate short-term anticonvulsant medication 3.
- Long-term anticonvulsant prophylaxis is usually not indicated when drug intoxication or withdrawal is the sole cause of a seizure 4.