Seizures, Syncope and other Non-

Magical Spells

Dr. Chris Hahn

Internal Medicine Clerkship Lecture Series
 In the next hour…
• Seizure definitions & epidemiology
• Recognize and characterize seizures
• Differential diagnosis of a ‘spell’
• Take seizure history
• Examine ictal & post ictal patients
• How and when to investigate a first seizure
 What we will not talk about…
• Epilepsy and specific epilepsy syndromes
• Detailed discussion of AEDs
• EEG
• Non medical spells
 A Case
• You’re on call for MTU
• Charge pages you and asks you to assess Mr.M
for a possible ‘seizure’
 Mr.M
• 69 year old man
• Admitted with COPD exacerbation
• Has a history of CKD, HTN, CAD, A.fib on
Warfarin
 Mr.M
• His bedside nurse was walking him to the
bathroom when he suddenly fell to the
ground
• Was unresponsive and then gradually woke up
over a few minutes
• He is now back in bed and complaining of
generalized weakness
 Definitions
• Seizure
– Occurrence of signs and symptoms due to
abnormal excessive or synchronous neuronal
activity in the brain
• Epilepsy
– Condition of enduring predisposition to generate
epileptic seizures
 Types of Seizures
Seizure

Focal Generalized

Nondyscognitive Dyscognitive Myoclonic Atonic

Secondarily
Tonic Clonic Tonic
generalized

Clonic
 Definitions
• Status Epilepticus
– Either of
• (practical definition) 5 min or longer of continuous
seizure
• two or more seizures between which there is in-
complete recovery of consciousness.
– Requires prompt recognition and management
– SE associated with significant morbidity and
mortality
– Approx. ½ of SE occur in patients w/o a seizure Hx
 Epidemiology
• In the population
– Up to 10% will have a seizure in their lifetime
– Only 0.5-1% have Epilepsy
• Seizure etiology varies with age
CHILDREN YOUNG (15- OLDER (65+)
MIDDLE AGED
(0-15) 34) (35-64) 1. Old Stroke
1. Trauma 2. Tumor
1. Infection 1. Drugs/Toxic
3. Drugs/Toxic
2. Metabolic 2. Drugs/Toxic 2. Old Stroke
4. Metabolic
3. Trauma 3. Metabolic 3. Tumors
 History

• COLLATERAL IS KEY

Before
Pre-Ictal During
Ictal After
Post Ictal

Characterize the Event

 History: Profile
• Past medical history
• Meds – changes? New? Withdrawal?
• SH – drug use, drug withdrawal
 History: Before
• Triggers
– Sleep deprivation/stress/illness
– Drugs or new medications
– Medication noncompliance
– Standing up quickly
 History: Before
• Preceding symptoms
– Aura or warning
– Cardiac symptoms (SOB, palpitations, chest pain)
– Dizziness/lightheadedness
– Feeling flushing
– Diapheresis
 History: During
• Limb shaking
• Eyes open or closed
• Head turning during event
• Tongue biting
• Bowel/bladder incontinence
 Types of Seizures
Seizure

Focal Generalized

Nondyscognitive Dyscognitive Myoclonic Atonic

Secondarily
Tonic Clonic Tonic
generalized

Clonic
 History: After
• Confusion
• Weakness
• Muscle soreness
• Fatigue
• Urinary/bowel incontinence
 Post Ictal Sate
• Transient period of brain recovery lasting seconds to hours
• Can be prolonged in those with poor neurologic
reserve…several days
• Commonly:
– Altered LOC (confusion, drowsiness, agitation)
– Focal neurologic deficits
• UMN sign’s
• Todd’s paralysis
• Less commonly – aphasia, vision loss, sensory deficits
Seizure vs Syncope
http://www.medicalgrapevineasia.com
 Pseudoseizures
• a.k.a Paroxysmal non-epileptic seizures (PNES)
• A type of conversion disorder
• Commonly co-exists in those with epilepsy
• Often triggered by stressful situations,
presence of an MD
• Often prolonged spells
• Often have psychiatric co-morbidities
 Seizures

Primary Secondary
(epilepsy) or Provoked
 Causes
• Neurologic
• Metabolic
• Infectious
• Toxic/Drugs
• Other
 Causes of Seizures
• Neurologic
– Structural lesions
• Tumors
• Strokes (usually old)
• Bleeds
• Trauma
– CNS infections
• Meningitis/encephalitis
• Fungal
• Abscess
– Dementia
 Causes of Seizures
• Metabolic
– Electrolytes: Ca, Na, Mg
– Hypoglycemia
– Hyper-uremia
– Liver failure
– Hyperthyroidism
 Causes of Seizures
• Toxic
– Drugs – cocaine, meth, stimulants
– EtOH/BZD withdrawal
– Medications
• Antibiotics
• Theophylline
• Antidepressants (TCA)
• Lithium
 Causes of Seizures
• Other
– HTN
– Hypoxia
 Exam
• ABC’s, Vitals • Neuro exam as
• Survey for trauma, appropriate for pt’s
injuries LOC
– Tongue/mouth bites – E.g. comatose exam vs
full exam if alert
– incontinence
• Assess LOC, GCS • Observe: abnormal
posturing, movements,
vocalizations
 Investigations
• Extended lytes • Consider:
• Bedside glucose – CT head*
• Creatinine, Urea, LFTs, – Lumbar Puncture
TSH – Cultures
– Blood gas
• Tox screen
– EEG
– AED levels, etc.
 EEG
Why bother?
• If you’re not sure it was a seizure
• If you’re worried about non-convulsive status
• If you want to localize a seizure focus
 EEG
• Routine 30 minute EEG
– Sensitivity: 30-40%
• How can you increase sensitivity
– EEG within 24h of seizure ~50% sensitive
– Sleep deprivation (20-40% increase)
 Neuroimaging
• Indicated whenever there is not a clear history
of provoked seizure
• CT – mass lesion, hemorrhage, large infarct
– Suitable for ED work up
– Changes management in ED 10-15% of the time
• MRI – subtle structural abnormalities
 Management
• ABC’s, frequent vitals
• Remove nearby dangerous objects
• Position patient on their side
• SpO2 monitoring & apply O2
• IV access
• Treat the cause
 Management
• Not everyone needs an AED (or ativan or
dilantin)
• If the seizure is brief (< 2-3 min) and
terminates then it is reasonable to watch and
wait
– Especially if there is a clear provoking factor which
can be treated
 Doctor, can I drive?
COMMERCIAL:
Single, PRIVATE:
unprovoked No driving >3m
No driving
seizure NYD 3m If no seizures x 12m,
may resume driving*

PRIVATE: COMMERCIAL:
After
seizure
Diagnosis seizure free x 5y & on
free x 6m
of Epilepsy AED
& on AED
 When to start AEDs?
• Not usually indicated in first seizure with
normal work up, especially if provoked seizure
• Often AEDs are discussed after 2 seizures
• Not necessarily life long
 Back to Mr.M
• 69 year old man
• Admitted with COPD exacerbation
• Has a history of CKD, HTN, CAD, A.fib on
Warfarin
 Mr.M
• His bedside nurse was walking him to the
bathroom when he suddenly fell to the
ground
• Was unresponsive and then gradually woke up
over a few minutes
• He is now back in bed and complaining of
generalized weakness
 History

Before
Pre-Ictal During
Ictal After
Post Ictal

Characterize the Event

 Further History
• No warning
• Let out a moan and then collapsed to the floor
• 4 limb shaking for 30 seconds
• Incontinent of urine
• Confused for 15-20 minutes afterwards
 On exam
• He is drowsy but rousable
• Right facial droop
• Right arm > leg weakness
• Upgoing toes
 If you remember nothing else
• Get a good history from a witness
• Causes
– Check their glucose
– Check their electrolytes (Na, Ca)
– Check their medications
– Check their bag (for EtOH)
• If you check a Dilantin level, always check
albumin as well
Questions?