Seizure

Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow — check first
Diagnostic flow — check first
  • Glucose first — fix hypoglycemia immediately.
  • Time the seizure: ≥5 min = status, start benzo NOW.
  • Pregnant > 20 wk = eclampsia until proven otherwise → magnesium.
  • Focal onset, trauma, or anticoag → CT head (without contrast).
  • Look for tox cause (INH [isoniazid] → B6; TCA → bicarb; sympathomimetic → benzo).
Differential diagnosis — checklist
0/17

Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.

Structural / CNS0/4
Metabolic / toxic0/6
Epilepsy-related0/3
Mimics0/4
Initial ED workup
Bedside0/4
  • POC glucose IMMEDIATELY
  • Airway / position lateral decubitus, suction, O2
  • Continuous cardiac monitor + pulse ox
  • Pregnancy test in females of reproductive age
Labs0/7
  • BMP (Na, Ca, Mg)
  • CBC
  • AED levels if on therapy
  • LFTs, ammonia (valproate)
  • VBG, lactate
  • Tox screen
  • Pregnancy test
Imaging0/3
  • Non-contrast CT head (first seizure, focal, trauma, anticoag)
  • MRI brain (with & without contrast) — outpatient for first unprovoked
  • EEG (admission or outpatient)
Initial management0/7
  • ABCs, IV access x2, O2, monitor; protect from injury, do not restrain.
  • Treat reversible causes: glucose, Na, Mg, B6, magnesium for eclampsia.
  • STATUS (≥5 min or recurrent without recovery):
  • 1) Lorazepam 4 mg IV (peds 0.1 mg/kg) or midazolam 10 mg IM (peds 0.2 mg/kg) — repeat once at 5 min
  • 2) Levetiracetam 60 mg/kg IV (max 4.5 g) OR fosphenytoin 20 mg PE/kg IV OR valproate 40 mg/kg IV
  • 3) Refractory: intubate (RSI w/ rocuronium to avoid masking seizure) + continuous infusion (midazolam, propofol, ketamine)
  • Continuous EEG if persistently altered after seizure stops.
ED next steps
ED next steps
  • Glucose, IV, O2, monitor.
  • If actively seizing ≥5 min: lorazepam 4 mg IV or midazolam 10 mg IM.
  • Second-line AED if seizure persists or recurs (levetiracetam preferred).
  • Labs + CT head (without contrast); LP if febrile / immunosuppressed / persistent AMS.
  • Admit: status, persistent AMS, new structural lesion, eclampsia.
  • Discharge first unprovoked seizure if back to baseline w/ neuro f/u; counsel on driving restrictions.
Pearls / pitfalls
Pearls
  • Benzo dose under-dosing is the #1 cause of refractory status — give the full dose.
  • Avoid phenytoin push faster than 50 mg/min (hypotension, arrhythmia); use fosphenytoin.
  • Postictal Todd paralysis can mimic stroke — resolves over hours.
  • Always check pregnancy in reproductive-age females — eclampsia changes everything.