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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 develop an approach to dealing with them. Distinguishing among the types and causes of acute seizures and managing them is an important training problem for medical students.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with SEIZURES can include:

Medical Knowledge Learning Topics related to SEIZURES

1. Diagnosis of seizures (convulsive and non-convulsive), maintenance of patient safety during acute seizures, and application of Advanced Convulsion Evaluation and Therapy

2. Criteria distinguishing:

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

3. 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. Signs and symptoms associated with most common causes of acute seizures that help to differentiate etiologies

5. Diagnostic criteria of acute seizures and the differences in clinical presentation and pathophysiology for each etiology

6. Utility of diagnostic tests in the evaluation of acute seizures, including 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. Management of 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. Critical pathway for acute seizures:

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

Diagnostic Evaluation Learning Topics related to SEIZURES

1. Age-appropriate medical history, that differentiates among etiologies of disease, including elicitation of appropriate information from patients with acute seizures and/or their families

2. 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. Acute therapy of acute seizures

4. 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. 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. 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. Utility and interpretation of laboratory and clinical tests both prior to and after initiating treatments, based on the differential diagnosis. 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. Basic and advanced procedures:

  • performance a venipuncture for collection of blood specimens• insertion a peripheral venous catheter
  • collection of an arterial blood gas
  • assistance in performing a lumbar puncture after explaining the procedure to the patient
  • insertion of a urinary catheter

Management Plan Learning Topics related to SEIZURES

1. Indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with acute seizures
2. Treatment for the patient with acute seizures based on the diagnosis, evidence about treatment options, patient characteristics, and patient preferences
3. Appropriate fluids for the treatment of hyper/hyponatremia, hyper/hypoglycemia, and hypercalcemia
4. Use of insulin and glucose for the treatment of hyper/hypoglycemia
5. Order antibiotics for the treatment of meningitis, encephalitis and brain abscess.
6. Involvement of a neurologist in the management of patients with acute seizures
7. Prognosis for the patient with acute seizures based on the diagnosis, the treatment plan, and the patient’s characteristics
8. Communication of the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner. Consideration of the patient’s knowledge and ability to comprehend new information. 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. Education for the patient about his or her treatment plan
10. Patient counseling about seizure prevention (avoid triggers, including sleep deprivation)
11. Refer for psychological support if indicated
12. Follow-up planning

Potential Differential Diagnosis Topics Include:

  • 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