Fitri Octaviana

Neurology Department, Faculty of Medicine University of Indonesia

Cipto Mangunkusumo Hospital

Neuroemergency PLD 2012 6/4/2012

Introduction

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Seizure

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Epileptic Seizure

Transient occurrence of signs and/or

symptoms due to abnormal excessive
or synchronous neuronal activity in
the brain

ILAE, 2005

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 Epilepsy

ILAE, 2005
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Epilepsy

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Seizure types

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Secondary Generalized
Seizure

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Differential diagnosis of
epileptic seizure

Syncope

Hypoglycemia

Alcohol , drugs

Psychogenic seizures

Hyperventilation syndrome

Transient ischaemic attack

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Evaluation of First Seizure

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Anamnesis

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Physical Examination

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Laboratory

Serum glucose and sodium level

Alcohol test

Pregnancy test should be obtained if a woma
is of childbearing age

ECG

Others laboratory tests, toxicology screening,
lumbar puncture if clinically indicated

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Neuroimaging

If intracranial lesions is suspected

 New focal deficit or persistent altered mental
state, fever, persistent headache, focal or partial
onset before generalization, or a history of acute
head trauma, malignancy, imunocompromised

If follow-up cannot be ensured

MRI is preferable to CT

In acutely ill patients, CT Scan is modality of
choice.
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MRI-FLAIR

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EEG

To distinguish between epileptic seizure or

non-epileptic seizure

To distinguish between generalized or partial
seizure

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Indication of admissions

Fever or signs suggestive of infection

Prolonged seizure for more the 5 minutes

Recurrent seizures (e.g. 2 generalized seizure
within 24 hours)

Incomplete recovery after a seizure

Persistent post-ictal focal neurolgical deficit

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Admission

Patients who have fully recovered, have no

neurological deficit, and have normal initial
investigations can be discharged from ED

Admission should be considered in all

patients with alcoholism or those without a
responsible adult to stay with.

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Treatment

Anti-epileptic Drugs (AED) should not

routinely be prescribed in the Emergency
Units.

If AED are to prescribed, should only be after
consultation with a neurologist or neuro-
pediatricians.

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 AED
Parsial Generalized
SPS Tonic-clonic Absence
CPS Myoclonic
2GTC Tonic
Atypical absence
Atonic
Phenytoin, carbamazepine, Ethosuximide
phenobarbital, oxcarbazepine,
gabapentin, pregabalin, tiagabin.

Valproate, lamotrigin, topiramate, levetiracetam, zonisamide,

felbamate
Advice

Patients should be given verbal and written

advice about driving and lifestyle changes
prior to being discharged from emergency
unit

Advice given to patients should be

documented in the medical notes

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General advice to pts after
1st seizure

Stop driving

Should not operate dangerous machinery or
work at height

Caution should be applied for certain at risk
hobbies (swimming, hiking)

Avoid sleep deprivation and alcohol

Dietary restriction is not necessary

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Follow up

All patients should be followed-up by a

neurologist or epilepsy specialist urgently,
ideally within 2 weeks

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Risk factors of Recurrent
seizure

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Status Epileptikus

≥2 epileptic seizures without fully neurological

recovery between seizure

OR

Epileptic seizure last > 30 minutes

Practically: epileptic seizure > 5 minutes

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Epilepsia 2007;48(9):1652-1663
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Algorithm

Diazepam 0.2 mg/kg IV over 1-2 min

(repeat 1x if no response after 5 min)

Seizure continuing

Fosphenytoin 20mg/kg IV @ 150mg/min

Phenytoin 20mg/kg IV @ 50 mg/min

Seizure continuing

Fosphenytoin 5-10mg/kg IV @ 150mg/min

Phenytoin 5-10mg/kg IV @ 50 mg/min

Seizure continuing Consider valproate

25 mg/kg IV

0 10 20 30 40 50 60 70 80
Time (minutes)Neuroemergency PLD 2012 6/4/2012
 Seizure continuing Consider valproate
25 mg/kg IV

Phenobarbital
20mg/kg IV at 50-75 mg/min

Seizure continuing
Proceed immediately to anaesthesia with
midazolam or poropofol if the patient develops
status epilepticus while in the intensive care unit, Phenobarbital
has severe systemic disturbance or has seizure (additional 5-10 mg/kg)
that have continued for more than 60 to 90 minutes

Seizure continuing

Anesthesia with midazolam or

propofol

0 10 20 30 40 50 60 70 80
Time (minutes)

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Epilepsia, vol 47, Suppl 1, 2006
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Prognosis of SE

Mortality: 17-23%

Neurologic deficit post SE: 11%

Outcome predictor:
 Age: > 60 yo mortality 38%
 Etiology (symptomatic seizure has non favorable
prognosis)
 Duration SE > 1 hour mortality 34.8%, < 1 hour
mortality 3.7%
 ECG changes  higher mortality

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Take home messages

Define underlying disease if there is first

seizure

Stop seizure immediately

Prolonged seizure has poor outcome

Initiation of AED should be made by
neurologist or epilepsy specialist.

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Is it seizure?

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