Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Seizures and epilepsy in the acute medical setting: presentation and management

Elizabeth Caruana Galizia and Howard John Faulkner
Download PDF
DOI: https://doi.org/10.7861/clinmedicine.18-5-409
Clin Med October 2018
Elizabeth Caruana Galizia
ADepartment of Neurology, Atkinson Morley Wing, St George's Hospital, London, UK
*authors contributed equally
Roles: consultant neurologist
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Howard John Faulkner
BDepartment of Neurology, Southmead Hospital, Bristol, UK
*authors contributed equally
Roles: consultant neurologist
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: Howard.Faulkner@nbt.nhs.uk
  • Article
  • Figures & Data
  • Info & Metrics
Loading

ABSTRACT

Epileptic seizures are a common cause for presentation to acute medical services. Whether presenting with an isolated, unprovoked seizure or with status epilepticus, a good understanding of seizures and their mimics ensures appropriate investigation and treatment. This article describes the practical aspects of the management of patients presenting with seizures to the emergency department or the acute medical unit.

KEYWORDS
  • seizures
  • epilepsy
  • status epilepticus
  • transient loss of consciousness
  • classification

Key points

  • Transient loss of consciousness is common, with syncope, epileptic seizures, and non-epileptic seizures accounting for most presentations

  • History, including a witness account where possible, is key

  • Consider urgent brain imaging in specific circumstances

  • Seizures may be provoked or unprovoked and identifying the underlying cause has implications for treatment and onward referral

  • Status epilepticus is a medical emergency; timely treatment, delivered in appropriate doses are paramount

Introduction

Seizures are one of the commonest causes of transient loss of consciousness presenting to acute medical services and epileptic seizures are the commonest cause of short admissions among the neurological conditions. While not all seizures are associated with lost consciousness, most requiring acute medical care will involve impaired awareness and responsiveness. Approximately 1% of the UK population are treated for epilepsy, with around 0.5 new cases per 1,000 population every year.1 Acute medical and emergency department physicians need a good working knowledge of the management of seizures and to be aware of seizure mimics.

Transient loss of consciousness

Transient loss of consciousness (T-LOC) is a common complaint that may present to many different specialties under various labels, including ‘blackouts’, ‘seizure’, ‘blank spells’, and ‘falls’.2 The term T-LOC itself is non-specific and includes all causes of self-limited loss of consciousness, regardless of mechanism.3 Syncope is the commonest cause of T-LOC, followed by epileptic seizures and non-epileptic seizures.3

A thorough history including a witness account will allow a diagnosis to be made in the majority of patients.4 Distinguishing seizures from syncope and functional non-epileptic seizures can be difficult, but these are equally important diagnoses to make. Patients with functional non-epileptic seizures are often exposed to inappropriate interventions and treatment with antiepileptic drugs. Diagnosing functional non-epileptic attack disorder and its management are covered in detail elsewhere in this issue. Syncope may be associated with a high mortality rate, likely reflecting a high-risk subgroup of patients5 and not uncommonly presents with myoclonic jerks, head turning, and other motor phenomena often associated with epileptic seizures;6 Sheldon et al,7 proposed a series of questions that they demonstrated would distinguish seizures from syncope with 94% sensitivity and specificity (see Table 1⇓).

View this table:
  • View inline
  • View popup
Table 1.

The Sheldon questionnaire. The patient has seizures if point score ≥1, and syncope if score is <1. The same questions can be asked of a witness

View this table:
  • View inline
  • View popup
Table 2.

Parameters for acute symptomatic seizures proposed by the International League against Epilepsy

Raised prolactin (within 30 min) or lactate following loss of consciousness can contribute to the distinction between bilateral tonic-clonic seizures and syncope or a non-epileptic attack, but are less helpful in the differentiation of non-convulsive episodes and are generally not recommended.8,9 Where the history is lacking, atypical, or inconclusive, early involvement of specialists experienced in the investigation and management of T-LOC improves diagnosis.10

First seizures

According to the National Institute for Health and Care Excellence (NICE) guidance,11 anyone with a suspected first seizure should be referred for specialist assessment and seen within 2 weeks. Most patients with a single self-terminating seizure who have made a full recovery can be managed as outpatients through local first-seizure pathways. Antiepileptic medication is not indicated for a single seizure, unless investigations indicate a high risk of seizure recurrence.12 Other than in status epilepticus, starting antiepileptic drugs should ideally be a specialist decision. In the interim, the patient should be given basic safety and driving advice.

  • Driving: by law patients must refrain from driving until specialist assessment. If a seizure is confirmed, the Driver and Vehicle Licensing Agency (DVLA) must be informed and a group 1 licence will usually be revoked for a minimum of 6 to 12 months (depending on the presence/absence of abnormalities on magnetic resonance imaging [MRI] / electroencephalogram [EEG]).

  • Safety and lifestyle: shower rather than bath; avoid heights / dangerous equipment; occupational/parenting guidance; first aid in the event of recurrent events; and who to contact.

Investigations: who should have urgent brain imaging and who should be admitted?

All patients with a first seizure presentation should be investigated with routine blood tests to exclude infection or metabolic disturbance and should have an electrocardiogram (ECG). The majority of uncomplicated first seizure patients do not require urgent brain imaging before discharge. MRI is the imaging modality of choice to investigate seizures and will be organised via a first seizure clinic. Urgent brain imaging (preferably with MRI, but with computed tomography [CT] if MRI is not available / feasible acutely) before discharge should be considered in those patients where an acute intracranial event is suspected (see Box 1).

View this table:
  • View inline
  • View popup
Box 1.

Indications for urgent brain imaging and/or hospital admission

Patients with abnormal imaging, prolonged or recurrent events, or incomplete recovery may justify a brief admission for more urgent (inpatient) medical and neurological assessment.13

Acute symptomatic seizures

This encompasses all seizures that occur in close association with a brain insult. The International League Against Epilepsy (ILAE) has proposed specific parameters where seizures can be called acute symptomatic (see Table 2).14 In these circumstances treatment should not be initiated unless there are multiple seizures, or if the patient is in status epilepticus, followed by prompt specialist input with respect to continuation. The risk of seizure recurrence is often minimal so long-term treatment with antiepileptic drugs is not required.

Seizures in known epilepsy

This is an extremely common scenario. Patients can present reporting deterioration in their usual frequency for a range of reasons including:

  • patient/family anxiety about perceived changes

  • intercurrent infections / systemic illnesses

  • alcohol and recreational drug use

  • medication related: eg poor adherence, changes in formulation/brand, during planned withdrawal / changes to medication, drug interactions with other prescribed and over the counter medications

  • new acute symptomatic seizures, for example due to a head injury.

The history is key. Is the seizure pattern unusual for the patient? Ask how often seizures occur at their worst or their best. Confusion about the patient's normal seizure pattern can occur in new environments, for example, a stranger may have called an ambulance unnecessarily. If the above precipitants have been excluded, fluctuations in seizure frequency may occur simply due to the natural variability of epilepsy.

If adherence has been poor, try to establish why, in order to address the root cause (eg side effects needing a change in drug/dose, forgetfulness – would a blister pack help?)

Investigations: ECG and screening bloods for sepsis and metabolic causes should include antiepileptic drug (AED) levels where possible to assess adherence. Try to resist the temptation for brain imaging unless there is a clear clinical indication (see Box 1) and EEG is rarely useful in this situation.

In addition to addressing the cause, management may involve simple reassurance.

Seek advice from the patient's usual treating team or local neurology services, but try to avoid escalating the dose of existing medications without specialist advice. If short-term rescue medications are required for safe discharge, consider using clobazam 10 mg at night as a temporary add-on therapy prior to specialist advice.

Status epilepticus

Status epilepticus (SE) is defined by 2 time points: the first time point is when a seizure has failed to self-terminate and has become ‘abnormally prolonged’ leading to the second time point when there is a risk of neurological damage and long-term consequences. SE may be convulsive or non-convulsive.15 Convulsive SE (CSE) is a medical emergency, operationally defined by tonic clonic seizures persisting (or recurring without recovery) beyond 5 min, with an increasing risk of morbidity and mortality if not controlled by 30 min. Treatment should be initiated at 5 min.

Most hospitals will have local protocols for the treatment of convulsive status epilepticus. A typical protocol is shown in Fig 1: all involve initial treatment with benzodiazepines (in adults typically up to 2 doses of 4 mg of lorazepam or 10 mg midazolam, which may include pre-hospital treatment by carers or paramedics,11 followed by AEDs for ongoing seizures. Phenytoin and phenobarbitone are the only AEDs currently licensed in this situation, with speed and adequate dosing (20 mg/kg for phenytoin, 15 mg/kg for phenobarbitone) probably being more important than choice of agent.

Fig 1
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 1

Algorithm for the treatment of convulsive status epilepticus. Adapted with permission from the American Epilepsy Society guideline 2016.19 The most important differential diagnosis of status epilepticus is non-epileptic seizures. Non-epileptic seizures tend to last longer than epileptic seizures and should be considered as a diagnosis before emergency antiepileptic drugs are administered. Alongside treatment, urgent investigations must be performed to confirm the cause of the status epilepticus.

CA2+ = calcium; FBC = full blood count; IV = intravenous; LFT = liver function test; Mg2+ = magnesium; U+E = urea and electrolytes; IM = intramuscular

Meta-analyses suggest equipotency of valproate (30–40 mg/kg, max 3 g) and levetiracetam (40–60 mg/kg, max 4.5 g) with phenytoin, although these are not yet licensed for use in SE.17 Presently there is insufficient evidence to recommend either drug ahead of existing therapies for management of SE pending the outcome of ongoing trials.18 Those with ongoing seizures despite appropriate treatment need urgent intervention with anaesthetic agents and management on an intensive care unit with local neurology input.

Non-convulsive status epilepticus (NCSE) is a more difficult diagnosis usually made based on EEG. Unlike CSE where early intervention is essential, aetiology is the principal determinant of outcome in NCSE rather than duration of seizures and thus escalating treatment prior to EEG is not indicated without specialist advice.16 Treatment usually involves the use of intravenous benzodiazepines under EEG control.

Classification

The classification of seizures and the epilepsies has recently been updated. A comprehensive review of the new classification is available on the ILAE website (www.ilae.org). Increasingly, one will see, and should start to use, the following terms in clinical practice:20

  • ‘partial’ is replaced by the term ‘focal’; this can be further qualified by whether awareness is retained or not, so that ‘complex partial’ becomes ‘focal unaware’ and ‘simple partial’ becomes ‘focal aware’

  • ‘secondarily generalised’ is replaced by ‘focal to bilateral tonic clonic’

  • for generalised onset seizures, seizures can be described as ‘generalised motor’, which would include tonic clonic seizures, or ‘generalised non-motor’, which refers to ‘absences’

  • ‘unknown onset’ and ‘unclassified’ have been added, acknowledging that, not uncommonly, seizure onset and aetiology cannot be defined.

Conclusion

Seizures and seizure-mimics are common presentations to emergency departments and acute medical units, either as isolated events or as a medical emergency in status epileptics. The history is key in the former situation, while speed in delivering appropriate treatment cannot be over-emphasised in the latter. Central to this is early input from the neurology or epilepsy team, that will guide appropriate investigation and, if indicated, the start of treatment.

  • © Royal College of Physicians 2018. All rights reserved.

References

  1. ↵
    1. Joint Epilepsy Council
    . Prevalence, incidence and other statistics. JEC, 2011. www.epilepsyscotland.org.uk/pdf/Joint_Epilepsy_Council_Prevalence_and_Incidence_September_11_%283%29.pdf
  2. ↵
    1. van Dijk N
    , Boer KR, Colman N, et al. High diagnostic yield and accuracy of history, physical examination, and ECG in patients with transient loss of consciousness in FAST: the Fainting Assessment study. J Cardiovasc Electrophysiol 2008;19:48–55.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA)
    et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30:2631–71.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Reuber M
    , Chen M, Jamnadas-Khoda J, et al. Value of patient-reported symptoms in the diagnosis of transient loss of consciousness. Neurology 2016;87:625–33.
    OpenUrl
  5. ↵
    1. Soteriades ES
    , Evans JC, Larson MG, et al. Incidence and prognosis of syncope. N Engl J Med 2002;347:878–85.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Lempert T
    , Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994;36:233–7.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Sheldon R
    , Rose S, Ritchie D, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol 2002;40:142–8.
    OpenUrlFREE Full Text
  8. ↵
    1. Matz O
    , Zdebik C, Zechbauer S, et al. Lactate as a diagnostic marker in transient loss of consciousness. Seizure 2016;40:71–5.
    OpenUrl
  9. ↵
    1. Chen DK
    , So YT, Fisher RS, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005;65:668–75.
    OpenUrlPubMed
  10. ↵
    1. Briggs R
    , Coughlan T, Doherty J, et al. Investigation and diagnostic formulation in patients admitted with transient loss of consciousness. Ir Med J 2017;110:563.
    OpenUrl
  11. ↵
    1. National Institute for Health and Clinical Excellence
    . Epilepsies: diagnosis and management [CG137]. London: NICE, 2012.
  12. ↵
    1. Marson A
    , Jacoby A, Johnson A, et al. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial. Lancet Lond Engl 2005;365:2007–13.
    OpenUrl
  13. ↵
    1. Dunn MJG
    , Breen DP, Davenport RJ, Gray AJ. Early management of adults with an uncomplicated first generalised seizure. Emerg Med J 2005;22:237–42.
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Beghi E
    , Carpio A, Forsgren L, et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010;51:671–5.
    OpenUrlCrossRefPubMed
  15. ↵
    1. Trinka E
    , Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus – Report of the ILAE task force on classification of status epilepticus. Epilepsia 2015;56:1515–23.
    OpenUrlCrossRefPubMed
  16. ↵
    1. Ferguson M
    , Bianchi MT, Sutter R, et al. Calculating the risk benefit equation for aggressive treatment of non-convulsive status epilepticus. Neurocrit Care 2013;18:216–27.
    OpenUrlPubMed
  17. ↵
    1. Yasiry Z
    , Shorvon SD. The relative effectiveness of five antiepileptic drugs in treatment of benzodiazepine-resistant convulsive status epilepticus: a meta-analysis of published studies. Seizure 2014;23:167–74.
    OpenUrl
  18. ↵
    1. Bleck T
    , Cock H, Chamberlain J, et al. The Established Status Epilepticus Trial 2013. Epilepsia 2013;54:89–92.
    OpenUrl
  19. ↵
    1. Glauser T
    , Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr 2016;16:48–61.
    OpenUrlPubMed
  20. ↵
    1. Fisher RS
    , Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: position paper of the ILAE Commission for Classification and Terminology. Epilepsia 2017;58:522–30.
    OpenUrlCrossRef
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Seizures and epilepsy in the acute medical setting: presentation and management
Elizabeth Caruana Galizia, Howard John Faulkner
Clinical Medicine Oct 2018, 18 (5) 409-413; DOI: 10.7861/clinmedicine.18-5-409

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Seizures and epilepsy in the acute medical setting: presentation and management
Elizabeth Caruana Galizia, Howard John Faulkner
Clinical Medicine Oct 2018, 18 (5) 409-413; DOI: 10.7861/clinmedicine.18-5-409
Reddit logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • ABSTRACT
    • Key points
    • Introduction
    • Transient loss of consciousness
    • First seizures
    • Investigations: who should have urgent brain imaging and who should be admitted?
    • Acute symptomatic seizures
    • Seizures in known epilepsy
    • Status epilepticus
    • Classification
    • Conclusion
    • References
  • Figures & Data
  • Info & Metrics

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Functional neurological disorders: acute presentations and management
  • Assessment of acute headache in adults – what the general physician needs to know
Show more CME Neurology

Similar Articles

FAQs

  • Difficulty logging in.

There is currently no login required to access the journals. Please go to the home page and simply click on the edition that you wish to read. If you are still unable to access the content you require, please let us know through the 'Contact us' page.

  • Can't find the CME questionnaire.

The read-only self-assessment questionnaire (SAQ) can be found after the CME section in each edition of Clinical Medicine. RCP members and fellows (using their login details for the main RCP website) are able to access the full SAQ with answers and are awarded 2 CPD points upon successful (8/10) completion from:  https://cme.rcplondon.ac.uk

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2021 by the Royal College of Physicians