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Emergency Medicine at HCMC
History and Physical Exam:
A. Obtain from the paramedics or family members the history of the seizure – where,
when, witnessed?, and type of seizure.
B. Does the patient have a history of seizures, any medication taken
for seizures and are they taking their medication, if alcohol related,
how often do they have seizures, when was their last seizure, and any
change in seizure pattern (more often, change in type of seizure)
C. Any recent head trauma, fever, or history of headaches.
D. Physical – look for signs of trauma, lac to tongue, pupils,
and a full neuro exam. If the patient is post-ictal exam them as best
as possible and go back to do a full neurologic exam.
E. Are they waking up appropriately post-ictal?
Work-up
A. These patients need a pulse ox and accucheck.
B. Be sure they have a working IV.
C. Alcohol related seizures should receive IVF, Mag, Thiamine, Folate,
and some glucose.
D. Known seizure disorder – check drug levels of medications (free
Dilantin, Tegretol, or phenobarbital) and look for any signs that the
seizure pattern is changing.
E. New onset seizures – need work-up and admission to Neurology.
Labs including Panel 3 , Mag, Calcium, and Phosphorus. They also need
some type of imaging of their brain. If they have had recent head trauma
we often get a head CT without contrast. If they have a history of cancer
or HIV they may need a head CT with contrast. If it is the middle of
the day it is wise to call neurology early and let them be involved in
the decision of type of imaging.
F. Dilantin level is zero patient should be loaded at 18 mg/kg either
PO or IV. If loaded IV the patient needs to be on a monitor. If level
is low discuss with staff/senior on loading dosage.
G. Tegretol level is low, then patient needs a dose a 2x normal dosage.
You cannot load Tegretol.
H. Request old charts early, as they give you prior work-up information.
If they have had a recent head CT the results should be on IRIS.
I. Consider infectious cause for seizure in your differential. Any history
of fevers, recent travel, or meningeal signs. Be sure to think of meningitis,
neurocysticercosis, and HIV (toxoplasmosis, crypto, or lymphoma).
Admission
A. New onset seizures go to the Neurology team often with a floor bed.
B. Renal patients with seizures go to the Renal team and Neurology will
often consult once in the hospital.
C. Neurosurgery – will take patients with seizures from recent
trauma. Call them to consult.
D. Tell the HUC the name, diagnosis, bed requested. Call the team and
turn in the paper work to the HUC.
For more information contact Richard
O. Gray MD.
Emergency
Medicine main page
Copyright © 2000 HCMC Emergency Medicine. All rights reserved.
Manual last modified: Wednesday May 07, 2003.
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