🩺 Seizure

A seizure is a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is defined as a tendency for recurrent unprovoked seizures. The initial management focuses on patient safety, airway protection, and terminating prolonged seizures (Status Epilepticus). Diagnostic efforts centre on distinguishing seizures from mimics like syncope or non-epileptic attacks and identifying any underlying structural or metabolic cause. Long-term management involves avoiding triggers and, if indicated, commencing anti-epileptic drugs (AEDs).

The history is often reliant on eyewitness accounts. Determine the '3 Ps': Pre-ictus (aura, triggers, prodrome), Ictus (nature of movements, eye-rolling, cyanosis, incontinence), and Post-ictus (confusion, drowsiness, focal weakness). Distinguish between generalised seizures (loss of consciousness from the start) and focal seizures (starting in one area, with or without impaired awareness). Ask about risk factors including previous head injury, family history, alcohol or drug use, and sleep deprivation. Review current medications for drugs that lower the seizure threshold (e.g., tramadol, ciprofloxacin, antidepressants).

During the ictus, observe for tonic-clonic movements, lateralizing signs, or automatisms. In the post-ictal phase, assess the Glasgow Coma Scale (GCS), check for airway patency, and look for injuries such as a bitten tongue (typically the lateral border) or shoulder dislocation (often posterior). Perform a full neurological exam to identify any focal deficits (Todd’s paralysis) or signs of meningism. Examine the skin for stigmata of neurocutaneous syndromes (e.g., café-au-lait spots) or evidence of drug use. Cardiac auscultation and ECG are necessary to rule out arrhythmia-induced convulsive syncope.

Vasovagal Syncope, Cardiac Syncope (e.g., arrhythmias), Psychogenic Non-Epileptic Seizures (PNES), Hypoglycaemia, Transient Ischaemic Attack (TIA), Migraine Aura, Alcohol Withdrawal Seizures, Eclampsia (in pregnancy).

Status Epilepticus (seizure >5 minutes or recurrent seizures without recovery), New focal neurological deficit post-ictally (that does not resolve), Head trauma, Fever/Meningism, Pregnancy (Eclampsia risk), Previous malignancy (Metastases).

An ECG is mandatory for all patients with blackout to rule out long QT or other arrhythmias. Basic bloods (FBC, U&Es, LFTs, Calcium, Magnesium, Glucose) are performed to identify metabolic disturbances. For a first unprovoked seizure, a non-contrast CT head is indicated acutely if there is head trauma, persistent confusion, or focal deficit. Specialist investigations include Electroencephalogram (EEG) and MRI Brain, though these are typically arranged in the 'First Seizure Clinic'. EEG is used to classify the epilepsy syndrome rather than 'rule out' epilepsy, as a normal inter-ictal EEG does not exclude the diagnosis.

Alcohol withdrawal and hypoglycaemia are common, reversible triggers in the ED—always check a 'Capillary Blood Glucose'. A 'wait and see' approach is often adopted after a single unprovoked seizure; treatment is typically initiated after the second event unless there is a high risk of recurrence (e.g., focal onset or abnormal imaging). Sodium valproate should be avoided in females of childbearing potential due to teratogenicity, unless there is no alternative. Always document if there was tongue biting (especially lateral) and the duration of the post-ictal phase to help differentiate from syncope.

Fits the 'Emergency Medicine' and 'Neurology' domains. Candidates must know the Step C management of Status Epilepticus (benzodiazepines followed by phenytoin/levetiracetam/valproate). Be aware of DVLA restrictions after a first seizure (typically 6 months off driving for a single event, 12 months for epilepsy).