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Journal of the American Academy of Physician Assistants:
doi: 10.1097/01.JAA.0000431518.51314.3d
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Seizure disorder

Dill, Linda Jo MS, PA-C, PhD

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Author Information

Linda Jo Dill is an associate professor and academic coordinator of the PA program at York College-City University of New York in New York City. The author has indicated no relationships to disclose relating to the content of this article.

Amy M. Klingler, MS, PA-C, and Dawn Colomb-Lippa, MHS, PA-C, department editors.

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* A seizure is an abnormal motor, sensory or mental function caused by a series of synchronous, high-frequency neurons discharged from the cortical or subcortical brain centers.

* Non-epileptic (secondary or reversible) seizures. Common causes: Benzodiazepine or alcohol withdrawal, meningitis, stroke, renal dialysis, high fever in children.

* Epileptic seizures (epilepsy)

* Primary disorder of recurrent seizures without a reversible metabolic cause.

* Diagnosis usually made when a patient has had two unprovoked seizures within 24 hours.

* Febrile seizures are tonic-clonic type seizures associated with fever above 38.8° C (101.8° F), which typically occur in children ages 3 months to 6 years.

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* Primary generalized: Begin in one area of the brain; rapidly spread throughout both brain hemispheres and involve an alteration of consciousness.

* Tonic-clonic (grand mal) phases in order of occurrence:

* Aura: Abnormal sensations, emotions, altered vision, or hearing that frequently precede a tonic-clonic seizure.

* Tonic (stiffening) phase: Sudden loss of consciousness, skeletal muscle tension, and brief apnea.

* Clonic (jerking) phase: Violent, rhythmic muscle contractions alternating with muscle relaxation; respirations resume.

* Postictal phase: Transient confusion, drowsiness, and/or agitation, excessive salivation, and possible bowel or bladder incontinence.

* Recovery phase: Gradual return to consciousness; patients often sleep for several hours.

* Absence (petit mal)

* Occur primarily in children.

* “Blanking out” spells (brief, abrupt altered consciousness).

* Patient stares ahead and stops talking, responding, and performing activities for a few seconds.

* Classic 3 Hz “spike and wave” pattern seen on EEG.

* Myoclonic

* Intermittent brusque, brief, single, or multiple rapid muscular jerking movements.

* Involve a single muscle, part of a muscle, a localized site such as the face, trunk or an extremity, or the entire trunk musculature.

* No altered consciousness.

* Status epilepticus

* Life-threatening emergency.

* Prolonged seizure lasting longer than 5 minutes, or recurrent seizures without recovery of consciousness for longer than 5 minutes between episodes.

* May progress to coma and death.

* Partial (focal): Involve a single area of the brain in only one cerebral hemisphere; no spread to other brain areas.

* Simple partial

* May present with motor signs such as twitching, jerking movements of an extremity, the face, eyes, or other body area, or a sensory disturbance, such as flashing lights or gustatory hallucinations.

* May include autonomic features (pallor, flushing, sweating, piloerection, pupil dilation, salivation, or vomiting).

* No altered consciousness.

* Complex partial

* Bizarre, complex motor behaviors such as wandering about, chewing motions, lip smacking, or picking at clothing.

* Altered consciousness (dream-like state).

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* History: Need to assess patient's current medications, such as psychotropics, opioids, antimicrobials, chemotherapeutic agents, stimulants, antiarrhythmics, antihistamines, bupropion, venlafaxine, or others that may lower seizure threshold.

* Past medical history: Head injury, stroke, Alzheimer disease, CNS infection, drug or alcohol abuse.

* In children: Assess illness (including fever), developmental delays, or perinatal injury.

* Determine compliance with medications if patient is known to be on antiseizure medication.

* Family history: Seizure in family member is highly suggestive of seizure disorder.

* Document if seizure was witnessed, by whom, with description of seizure activity and duration of symptoms.

* Physical exam:

* Vital signs: Patient may be febrile, which should alert clinicians to the possibility of fever and seizures from an infectious cause.

* Examine patient for potential traumatic injuries incurred during seizure activity, especially intraoral and head trauma.

* Neurologic examination should include complete cranial nerve examination, deep tendon and primitive reflex examination, and motor and sensory function of extremities. Complete a thorough examination to rule out any non-neurologic cause for seizure.

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* All patients with new onset of seizures need a neurology consult.

* Studies should include:

* EEG: Essential in evaluation of seizure to examine brain wave activity; differentiate seizure type.

* Magnetic resonance imaging (MRI): Generally preferred over computed tomography (CT) to rule out structural brain abnormalities.

* CT: Rule out brain tumor, hemorrhage, stroke, or other intracranial abnormalities if MRI is contraindicated or unavailable.

* Lumbar puncture: If infectious cause is suspected.

* Positron emission tomography (PET) or single photon emission computed tomography (SPECT): May localize the site of seizure activity.

* CBC and chemistry panel: Identify any potentially treatable causes of seizures.

* Consider serum creatine phosphokinase levels, which can help distinguish between partial and tonic-clonic seizures.

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* Pharmacotherapy is the mainstay of treatment, and must be individualized.

* Therapeutic goals: Prevent further seizure activity with minimal adverse drug reactions.

* Multiple medication options; selection based (in part) on seizure type.

* Monotherapy preferred; two or more medications may be combined if needed to control seizure activity.

* Monitor plasma drug levels for efficacy and/or toxicity.

* Lorazepam or diazepam are the initial drugs of choice for status epilepticus.

* Ethosuximide is the drug of choice for absence seizures.

* Carbamazepine is the least teratogenic; valproic acid is the most teratogenic.

* No treatment for febrile seizures except fever control (acetaminophen or ibuprofen).

* Surgical intervention may be considered if seizures are adversely affecting a child's life or development.

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© 2013 American Academy of Physician Assistants.


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