What are the steps to confirm and manage a seizure in a patient?

How to Confirm if a Patient is Having a Seizure

The most effective way to confirm a seizure is through direct observation of the event, clinical history, and electroencephalography (EEG) when available, especially for patients with impaired consciousness where seizure activity may not be clinically apparent. 1, 2

Initial Assessment and Confirmation

Direct Observation

• Look for characteristic seizure patterns:
  • Rhythmic motor movements (tonic-clonic activity)
  • Altered consciousness
  • Post-ictal confusion or drowsiness
  • Tongue biting
  • Urinary incontinence
  • Focal neurological deficits post-seizure

History Taking

• Document precise seizure characteristics:
  • Timing and duration of the event
  • Presence of aura
  • Level of consciousness during and after event
  • Motor activity patterns
  • Post-ictal symptoms (confusion, sleepiness, headache)
  • Risk factors (family history, brain injury/disease, substance use) 2

Diagnostic Testing

1. Laboratory Tests:

   • Serum glucose and sodium (essential for all patients)
   • Pregnancy test for women of childbearing age
   • Consider toxicology screen if altered mental status or suspected substance use 1, 2

2. Electroencephalography (EEG):

   • Gold standard for seizure confirmation
   • Continuous EEG monitoring for at least 24 hours is recommended for patients with impaired consciousness where seizures are suspected 1
   • Consider emergent EEG for suspected nonconvulsive status epilepticus or subtle convulsive status epilepticus 2

3. Neuroimaging:

   • CT scan may be performed initially in emergency settings
   • MRI is preferred when neuroimaging is indicated 2

Differential Diagnosis

It's crucial to differentiate seizures from other conditions that may mimic them:

• Syncope
• Psychogenic non-epileptic seizures
• Movement disorders
• Sleep disorders
• Migraine
• Transient ischemic attacks

Management of Active Seizures

For Active Seizure:

1. Ensure patient safety:

   • Help the person to the ground
   • Place in recovery position
   • Clear area to prevent injury 2

2. Monitor vital signs and maintain airway:

   • Ensure airway patency
   • Monitor respiration closely
   • Have ventilatory support available if needed 3

3. Medication administration for prolonged seizures:

   • For seizures lasting >5 minutes or multiple seizures without return to baseline:
     • First-line: Benzodiazepines (lorazepam 4 mg IV given slowly at 2 mg/min)
     • If seizures continue after 10-15 minutes, administer additional 4 mg IV dose 3
     • Second-line (if seizures persist): Fosphenytoin, levetiracetam, or valproate 1, 2

For Status Epilepticus:

Status epilepticus requires immediate intervention as it's a life-threatening condition:

1. Administer benzodiazepines as first-line treatment
2. If seizures continue despite benzodiazepines, administer second-line agents:
   • Fosphenytoin, levetiracetam, or valproate (all have similar efficacy) 1
3. For refractory status epilepticus, consider:
   • Propofol
   • Midazolam infusion
   • Pentobarbital infusion 2

Common Pitfalls and Caveats

1. Missing non-convulsive seizures:

   • Non-convulsive status epilepticus should be considered in any patient with confusion or altered mental status of unclear cause 4
   • Up to 50% of aspirations resulting from seizure-related dysphagia are silent and go unrecognized until complications occur 1

2. Inadequate monitoring:

   • Patients with seizures are more likely to die within 30 days after stroke than patients without seizures, emphasizing the importance of monitoring 1

3. Overlooking correctable causes:

   • Status epilepticus may result from correctable causes such as hypoglycemia, hyponatremia, or other metabolic derangements 3
   • Always check for these underlying causes and correct them promptly

4. Failure to provide adequate respiratory support:

   • The most important risk associated with seizure management is respiratory depression
   • Always ensure airway patency and monitor respiration closely 3

5. Prolonged post-ictal state vs. ongoing seizure activity:

   • Be alert to the possibility that sedative effects of medications may add to impairment of consciousness seen in the post-ictal state 3
   • Consider EEG monitoring to differentiate

By following this systematic approach to seizure confirmation and management, healthcare providers can ensure timely and appropriate care for patients experiencing seizures, potentially reducing morbidity and mortality associated with these events.