1. The Management of the First Seizure
Dr Mohammed Tahir
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 1
from Tony Holley)

2. Aims
• To have an understanding of the common
causes of a first seizure presenting to the
Emergency Department
• To have an understanding of the basic
management of the first seizure
• To have some basic rules for seizure
management
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 2
from Tony Holley)

3. Definition of Seizure
An episode of abnormal neurological functioning
caused by abnormal discharge of neurons!
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 3
from Tony Holley)

4. Classification of Seizures
• Generalised - loss of consciousness
• Partial - no loss of consciousness
• Unclassified
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 4
from Tony Holley)

5. Classification of Seizures
Generalised Partial
• Absence Simple Partial
• Motor
• Tonic Clonic
• Sensory
• Myoclonic • Autonomic
• Clonic Complex Partial
• Tonic • With psychic, cognitive or affective
symptoms
• Atonic • With automatism's
Partial seizures with
secondary generalisation
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 5
from Tony Holley)

6. Classification of Seizures by Etiology
• Acute Symptomatic seizures
• Remote Symptomatic seizures
• Idiopathic
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 6
from Tony Holley)

7. Acute Symptomatic seizures
CNS infections
• Meningitis
Neoplasms
• Encephalitis
• Abscess
• Benign
Vascular disease • Malignant - Primary,
• CVA
Secondary
• Vasculitis Metabolic
Trauma • Electrolyte disturbances
Hypertensive • Hypoglycaemia
Eclampsia • Hypoxia
• Renal Failure
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 7
from Tony Holley)

8. Acute Symptomatic seizures- Toxin Drugs
Tricyclic antidepressants Cocaine
Antidepressants Amphetamines
Theophylline Lignocaine
Withdrawal - ETOH, Anti -psychotics
benzo’s Antihistamines
Anticholinergics Isoniazid
Organophosphates
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 8
from Tony Holley)

9. Remote Symptomatic Seizures
• Previous head injury
• Previous CVA
• Congenital CNS disorders
• Previous hypoxic injury
• Previous CNS infections
• Degenerative diseases
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 9
from Tony Holley)

10. Incidence & Epidemiology
• 5% of the population have a seizure some
time in their life
• Bimodal frequency
• adult 1st generalised seizure accounts for 1%
ED visits
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 10
from Tony Holley)

11. Causes of seizures presenting to Emergency
Departments
Cause Sempere et al 1992 Henneman et al 1994
Idiopathic 27.6% 44.0%
Infarction 23.5% 11.0%
Cerebral Cystercercosis - 12.0%
ETOH 11.2% -
CNS infections 9.2% 10%
CNS tumour 8.2% 7.0%
Vascular Malformation 6.1% -
Trauma 4.1% 4.0%
Drug toxicity 3.1% -
Hyponaetraemia 2.0% 2.0%
Systemic Infection - 2.0%
Other 5.0% 9.0%
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 11
from Tony Holley)

12. Causes of seizures by age
Cause Age < 45 years Age > 45 years
Idiopathic 45% 15.5%
Infarction 2.5% 37.9%
ETOH 15% 8.6%
CNS infections 17.5% 3.4%
CNS tumours 2.5% 12%
Vascular Malformation 7.5% 5.2%
Trauma 7.5% 1.7%
Drug toxicity 0% 5.2%
Other 2.5% 10.2%
Sempere et al 1992
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 12
from Tony Holley)

13. Causes of seizures by age - acute
symptomatic seizures
• 6/12 to 5 years -Febrile convulsions
• Young adults -Trauma 26%
-Drug withdrawal 20%
• Elderly - CVA 44%
Annegers et al 1995
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 13
from Tony Holley)

14. Presentation to the Emergency Department
Differentiated Undifferentiated
• Febrile convulsion • Cardiac Arrhythmia's
• Idiopathic epilepsy • Vasovagal Episode
• Acute symptomatic • Cardiac - Structural
seizures • Blood loss
• Remote Symptomatic • Postural Hypotension
seizures • Sepsis
• Psychogenic
• etc
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 14
from Tony Holley)

15. Presentation to the Emergency Department
• Has the patient had a seizure?
• What kind of seizure was it?
• Was there a focal component?
• Was this the first seizure?
• Is there a family history of seizure disorder?
• Why did the seizure occur?
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 15
from Tony Holley)

16. Other Important History
• Systemic illness
• drug use/abuse
• pregnancy
• mental retardation
• head injury
• unexplained bruises/tongue biting
• nocturnal enuresis
• precipitants
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 16
from Tony Holley)

17. Management
• Historical documentation of the seizure
• Physical examination
• Investigations
• Cessation of seizures
• Observation
• Disposal
• Advice
• Seizure Prophylaxis
• Follow up
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 17
from Tony Holley)

18. Investigations
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 18
from Tony Holley)

19. Rule
Always do a
glucose
on any one who is
having a seizure or
has had a seizure!
١٢/١٨/٢ Dr Laura Martin (with a little bit of help
from Tony Holley)
19

20. Scenario 1
• 17 year old girl
• Post first witnessed tonic clonic seizure
• Been out to a party the night before
• Uncle has epilepsy
• Now well, GCS 15, Vital signs normal
• Neurological exam normal
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 20
from Tony Holley)

21. Investigations
• Glucose
• Sodium
• Calcium
• Consider urine and pregnancy test
• CT [ MRI ] & EEG as outpatient
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 21
from Tony Holley)

22. Post first seizure advice
• Management of a seizure at home
• Safe activities
• Driving
• Who should know?
• Have I got epilepsy?
• Not life threatening
• Exacerbating factors
• Follow up
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 22
from Tony Holley)

23. Seizure recurrence
• Most common within the first 6 months
• More than 50% of those who have recurrence
will occur within 6 months
• Rate varies from 36 -77%
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 23
from Tony Holley)

24. Seizure recurrence increased if
• Symptomatic Seizure
• History of epilepsy in a sibling
• Todd’s paralysis
• EEG abnormalities
• 2 seizures - 80-90%
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 24
from Tony Holley)

25. RULE
Seizure prophylaxis
for all first
symptomatic seizures
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 25
from Tony Holley)

26. Scenario 2
• 50 yr old woman
• Post tonic clonic seizure
• Husband said twitching started in her R arm,
then progress to LOC.
• History of recent headaches.
• Now well, GCS 15, appears neurologically intact
• Vital signs normal
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 26
from Tony Holley)

27. RULE
ALWAYS LOOK IN
THE FUNDI
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 27
from Tony Holley)

28. RULE
First Focal
Seizure = CT
scan!!!!!!
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 28
from Tony Holley)

29. Scenario 3
• 50 yr old woman
• Post generalised seizure
• Previously well, no seizures in the past
• Recent headache for 24 hours, unwell & fever
• Now GCS 13, Temp 39.8
• Confused, unco-operative 30 minutes post seizure
• Moving all limbs.
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 29
from Tony Holley)

30. Who to CT?
• Focal seizures
• trauma
• anticoagulants
• alcoholics
• immunosuppressed
• fever,stiff neck,persistent headache
• focal neurology
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 30
from Tony Holley)

31. RULE
Do not LP a patient
who has a decreased
Glascow coma score!!
Treat first, CT & ask
questions later!!
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 31
from Tony Holley)

32. RULE
A GCS < 13 is a
relative
contraindication to
LP even after a
١٢/١٨/٢ normal CT!!
Dr Laura Martin (with a little bit of help
from Tony Holley)
32

33. Scenario 4
• A 75 yr old man
• Previous hypertension
• Post tonic clonic seizure
• Now GCS 15 but right arm weakness
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 33
from Tony Holley)

34. RULE
Focal neurology = CT
scan
Focal neurology does
not = LP
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 34
from Tony Holley)

35. Scenario 5
• 18 yr old man
• Rugby injury with LOC, scalp laceration
• Initially in ED GCS 15, vomited twice and
complaining of a headache
• Has tonic clonic seizure in ED. Self resolved
• Now GCS 12 - 2 minutes post seizure
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 35
from Tony Holley)

36. RULE
Trauma &
Seizure
= CT scan!!
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 36
from Tony Holley)

37. Status Epilepticus
• Continuous or repetitive seizures without time
for recovery
• neuronal injury can occur in less than 30min
• may be subtle
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 37
from Tony Holley)

38. RULE
• BEWARE THE
INTER-ICTAL
PATIENT
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 38
from Tony Holley)

39. Treatment of Status Epilepticus
• All patients who still fitting on arrival to ED
• fitting for more than 10min
• LONGER THE DELAY HARDER TO
CONTROL
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 39
from Tony Holley)

40. 0-5 minutes
• Confirm diagnosis
• Oxygen
• Airway & Breathing [ Consider ETT ]
• Vital signs
• IV access
• Glucose check
• Oximetry
• Lab
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 40
from Tony Holley)

41. 5-10 minutes
• If hypoglycaemic treat
• Adults 100 mg thiamine followed by 50 mls
50% glucose
• Children 2 mls/kg 25%
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 41
from Tony Holley)

42. 10-20 minutes
•0.1 mg/kg lorazepam at 2mg/min up to 4 mg total
or
•0.2 mg/kg diazepam at 5mg/min up to 20mg/min
Diazepam must be followed by a loading dose of
phenytoin
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 42
from Tony Holley)

43. Difficult access?
• IM midazolam 10mg
• PR diazepam 0.5 mg/kg
• PR lorazepam 0.1mg/kg
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 43
from Tony Holley)

44. 20+ minutes
• Load with phenytoin 20 mg/kg no faster than
50 mg/min in adults and 1mg/kg/min in
children
• IV fluids must be N Saline
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 44
from Tony Holley)

45. If Status continues
• 1. Additional phenytoin 5 mg/kg up to a total of
30 mg/kg
• 2. Midazolam load 0.2 mg/kg infusion
• 3. Phenobarbitone 20mg/kg at max 100mg/min
• 4. Proprofol load with 0.2mg/kg then infusion
• Expect apnea
• Intubation will be required - rapid sequence
induction with thiopentone and suxamethonium
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 45
from Tony Holley)

46. Admission criteria for a first seizure
• Acute Symptomatic • Status epilepticus or
Seizure requiring prolonged seizure.
ongoing treatment & • Recurrent seizures
investigation • Social Situation
• Febrile seizure where
underlying cause needs
treatment or fever does
not settle
• Focal seizure
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 48
from Tony Holley)

47. Conclusion
No one seizure is the same
The clinician must always think of the
underlying cause & investigate & treat
appropriately
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 49
from Tony Holley)

48. References
• Em Clinics N America Feb 1999 17;1
• Emergency medicine reports Vol 18;14 1999
• Neurology Nov 1999 S4
• Lancet July 2000 Vol 356
١٢/١٨/٢ Dr Laura Martin (with a little bit of help 50
from Tony Holley)