Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Seizures

 

Because of the relatively frequent occurrence and potentially life threatening nature of acute seizure, and the fact that their etiologies and corresponding treatment strategies for these patients are varied, all medical students (physicians) need to have a minimum proficiency in dealing with them. Distinguishing among the types and causes of acute seizures and managing them is an important training problem for third-year medical students.

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Prerequisites

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Describe and discuss:

  • basic physiology
  • basic pathology
  • basic neuroanatomy

Demonstrate:

  • ability to take a medical history
  • ability to perform a physical exam
  • ability to perform a neurological and mental status exam

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Apply Medical Knowledge in the Clinical Encounter

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1.     For each patient encountered with acute seizures, a third year medical student should be able to:

  • diagnose seizures (convulsive and non-convulsive)
  • keep patient safe during an acute seizure
  • apply the Advanced Convulsion Evaluation and Therapy

(See “What To Do During Seizures” Neurology handout.)

2.     Describe the criteria used to distinguish:

  • status epilepticus from non-status epilepticus seizures
  • partial from primarily generalized, from secondarily generalized seizures
  • simple from complex seizures

3.     Describe the pathophysiology, signs, and symptoms of the most common and serious causes of acute seizures:

  • hyper/hyponatremia
  • hyper/hypoglycemia
  • hypercalcemia and hypomagnesemia
  • drug intoxication/withdrawal (AEDS, alcohol-related)
  • hypoxia, hypercarbia
  • cerebrovascular accident, vasculitis
  • encephalitis, brain abscess/tumor
  • hypertensive encephalopathy
  • febrile seizures
  • primary (genetically-based) seizures

4.     Describe signs and symptoms associated with most common causes of acute seizures that help to differentiate one etiology from another.

5.     Describe and discuss the key diagnostic criteria of acute seizures and the differences in clinical presentation and pathophysiology for each etiology.

6.     Discuss how diagnostic tests would help in the evaluation of acute seizures, including their indications and contraindications, limitations, and cost:

  • EEG
  • lumbar puncture
  • CT scan or MRI scan
  • drug screen
  • CBC with differential
  • electrolytes: sodium, calcium, magnesium
  • serum chemistries screen (glucose, renal/hepatic function tests)
  • arterial blood gases: oxygen, carbon dioxide, carbon monoxide

7.     Describe the principles of managing common causes of acute seizures:

  • ABCD+N+Rx
  • monitor vital signs
  • including pulse-ox
  • get bedside blood glucose
  • place urinary catheter
  • get CXR
  • EKG

8.     Describe the steps in a critical pathway for acute seizures:

  • Rx with lorazepam or diazepam
  • then Rx phenytoin
  • get EEG

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including eliciting appropriate information from patients with acute seizures and/or their families.

2.     Identify the semiology of the seizures and their temporal pattern, including the onset, duration, progression, recurrence, associated symptoms, potential causes (including medications), and level of physical and mental disability. 

3.     Discuss the acute therapy of acute seizures.

4.     Perform a physical exam, including a neurological status exam, to establish the diagnosis severity and complications of disease:

  • ictal aura, and post-ictal symptoms
  • appearance/body posture (tonic, clonic, both, other) during the seizure
  • level of alertness
  • speech/vocalization during the seizure
  • behavior/automatisms
  • awareness of environment
  • mood and affect
  • thought process and content
  • memory
  • ability to follow commands, including perform simple calculations
  • judgment
  • higher cortical functioning and reasoning
  • breathing pattern, cyanosis, pallor
  • sphincter incontinence

5.     Generate a prioritized differential diagnosis that recognizes specific history and physical exam findings that distinguish simple from complex seizures; focal, generalized and secondarily generalized:

  • level of consciousness
  • delineation of the aura
  • delineation of automatisms
  • identification of jacksonian/motor march
  • post-ictal paralysis (Todd’s)

6.     Generate a list of potential etiologies for the seizures:

  • a metabolic disorder
  • structural lesions (primary or metastatic tumor, intracranial hemorrhage, infection)
  • cerebrovascular accident, including hypertensive encephalopathy and vasculitis
  • central nervous system infections: meningitis, encephalitis, brain abscess
  • primary (genetically) based seizures
  • secondary/symptomatic seizures (ie: post-stroke, post-trauma, tumor/lesion-related, etc)

7.     Recommend when to order diagnostic, laboratory tests, and clinical tests both prior to and after initiating treatments, based on the differential diagnosis. Justify ordering them and interpret the results (with consultation). Consider test cost and performance characteristics as well as patient preferences. Consider the following tests:

  • lumbar puncture
  • CT scan
  • MRI scan
  • EEG
  • drug screen
  • CBC with differential
  • electrolytes
  • serum chemistries screen (glucose, renal/hepatic function tests)
  • VDRL
  • arterial blood gas
  • vitamin B12 and thiamine
  • thyroid function tests

8.     Perform selected basic and advanced procedures:

  • perform a venipuncture for collection of blood specimens
  • insert a peripheral venous catheter
  • obtain an arterial blood gas
  • assist in performing a lumbar puncture after explaining the procedure to the patient
  • insert a urinary catheter

9.     Record, present, research, critique, and manage clinical information.

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Develop a Management Plan

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1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with acute seizures.

2.     Design an approach to treatment for the patient with acute seizures based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences.

3.     Write appropriate fluid orders for the treatment of hyper/hyponatremia, hyper/hypoglycemia, and hypercalcemia.

4.     Write appropriate insulin and glucose orders for the treatment of hyper/hypoglycemia.

5.     Write appropriate antibiotic orders for the treatment of meningitis, encephalitis and brain abscess.

6.     Determine when to involve a neurologist in the management of patients with acute seizures.

7.     Formulate a prognosis for the patient with acute seizures based on the diagnosis, the treatment plan, and the patient’s characteristics.

8.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner. Take into consideration the patient’s knowledge and ability to comprehend new information and demonstrate an understanding of the emotional impact of a diagnosis of acute seizures and its potential effect on lifestyle (work performance, sexual functioning, motor vehicle driving, swimming, etc.).

9.     Provide education for the patient about his or her treatment plan.

10.  Provide counseling to patients when indicated about issues related to prevention (avoid triggers, including sleep deprivation).

11.  Refer for psychological support if indicated.

12.  Access and utilize appropriate information systems to ascertain information about health system and community resources such as support groups.

13.  Plan for follow-up.

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Differential Diagnosis

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  • drug intoxication/ withdrawal (AEDs, alcohol- related)
  • hypoxia, hypercarbia
  • hypertensive encephalopathy
  • febrile seizures
  • hyper/ hyponatremia
  • hyper/ hypoglycemia
  • hypercalcemia and hypomagnesemia
  • cerebrovascular accident, vasculitis
  • encephalitis, brain abscess/ tumor
  • primary (genetically-based) seizures