Neurology
Seizures
Objective
The primary objectives of the medical evaluation of the first seizure are to establish whether the event was a seizure, and if so, whether it resulted from a correctable systemic process or whether the patient is at risk for developing further unprovoked seizures
Seizures are further categorized as either focal or generalized according to whether the onset of electrical activity involves a focal region of the brain or the entire cortex simultaneously. The clinical manifestations of seizures vary based on the location of the seizure in the brain and the amount of cortex that is involved.
Cause
- genetic
- structural
- metabolic
- immune
- infectious
- unknown.
Differential Diagnosis
- syncope
- transient ischemic attack
- migraine
- psychogenic nonepileptic seizures.
Work-Up
- laboratory studies (electrolytes, glucose, calcium, magnesium, complete blood count, renal function tests, liver function tests, urinalysis, and toxicology screens),
- ECG
- EEG
- neuroimaging study
- Depending on the clinical situation, a lumbar puncture may also be indicated
Management
Antiseizure medications are not always indicated after a first seizure.
In criticaly ill patients, commonly used drugs in this setting include levetiracetam, fosphenytoin/phenytoin, and valproic acid
Hospitalization may be required for patients who have a first seizure associated with a prolonged postictal state or incomplete recovery. Other indications for hospitalization include status epilepticus, the presence of a systemic or neurologic illness or injury requiring additional evaluation and treatment, and questions regarding compliance
Seizure Disorders - American Family Physician (aafp.org)
Evaluation of First Nonfebrile Seizures - American Family Physician (aafp.org)
Evaluation and management of the first seizure in adults - UpToDate
AMS
Causes
CNS insults, Systemic Infections, Metabolic Disturbances, Toxin Exposure, Medications, Chronic Systemic Diseases, Psychiatric conditions
Definition
Change in consciousness, appearance, behavior, mood, affect, motor activity or cognitive function
Best Practice
Do not assume a diagnosis of dementia in elderly patients with AMS without assessing for delirium
Do not use physical or chemical restraints, outside of emergency situations. Assess for unmet needs or environmental triggers
Evaluation:
As the differential is broad, history and physical exam is always the first step to determine diagnostic testing.
- Evaluate ABC's
- Vitals, glucose, H&P
- Diagnostic studies as indicated by H&P
- Neuroimaging
- MRI brain or EEG or LP
- If still unclear, specialty consultation
Treatment
Definitive treatment is removal of the underlying cause
However, if patients' behaviors threaten self or others, then attempt nonpharmacologic interventions are the treatment of choice. This includes reassurance, family, friends and environmental factors.
Medications are used only when nonpharmacologic treatments are ineffective and only when it is essential to control behavior. These include antipsychotics, benzodiazepines and ketamine, but they contraindications and FDA warnings.
Recent-Onset Altered Mental Status: Evaluation and Management - American Family Physician (aafp.org)