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A convulsion is an episode of neurologic dysfunction caused by abnormal neuronal activity that results in sudden change in behavior, sensory perception, or motor activity. For a patient with new onset convulsion the list of possible causes is longer and consists of the following:
CNS pathologies (stroke, neoplasm, trauma, hypoxia, vascular abnormality)
Metabolic abnormalities (hypoglycemia/hyperglycemia, hyponatremia/hypernatremia, hypercalcemia, hepatic encephalopathy
Toxicological etiologies (alcohol withdrawal, cocaine, isoniazid, theophylline)
Infectious etiologies(meningitis, encephalitis, brain abscess, neurocycticercosis and malaria)
Approach to a patient:
Ask for history of epilepsy, if yes; compliance to anticonvulsant
History of CNS pathology(stroke, neoplasm, recent surgery)
History of systemic neoplasms, infections, metabolic disorders, or toxic ingestions
Recent trauma
Alcohol abuse TraumaEclampsia Intracranial hemorrhage Alcohol or medication withdrawal (barbiturate, diazepam) Drug induced seizures(tricyclic antidepressant and isoniazid overdose)
Laboratory studies:
Clinical information should guide the specific workup of a patient. Some investigations must be ordered:
Serum glucose level
Serum electrolyte
Pregnancy test for women of child bearing age
CT scan is indicated as outpatient/inpatient depending on progress of patient after episode of seizure. For a patient who had previously history of seizure do CT scan brain if;
- New focal deficits
- Trauma
- Persistent fever
- New character or pattern to the seizure
ECG should be considered in some patients. Seizure event can be precipitated by cerebral hypo-perfusion due to arrhythmia, ECG may identify the following
- Prolonged QTc
- Widened QRS
- Prominent R in aVR
- Heart block
Consider Lumbar Puncture in;
- Immune-compromised
- Persistent fever
- Severe headache
- Persistently altered mental status
Treatment and management
Neurological dysfunction is theorized to occur after 20mn of continuous seizure, so aggressive treatment of any seizure should be done in 5 min. always consider the underlying cause until proved otherwise.
- A, B, C (airway, breathing, circulation)
- Benzodiazepines
A:Diazepam 10-20mg IV at a rate of 0.5ml (2.5mg) per 30 sec. Repeat if necessary after 30-60min. May be followed by intravenous infusion to max. OR 3mg/kg over 24 hours, per rectum 500mcgrms/kg up to max of 30g)
B:Phenytoin 18mg/kg IV stat then 100mg 8 hourly O/IV C: Phenobarbitone 20mg/kg 8 hourly. Max. Dose 1.5g
References
https://en.wikipedia.org/wiki/Convulsion
https://www.medicalnewstoday.com/articles/324330
https://www.webmd.com/first-aid/convulsions-in-children
https://medlineplus.gov/ency/article/003200.htm
https://www.researchgate.net/publication/216226860_Basics_of_Convulsive_Disorders_Febrile_Seizures
https://www.epilepsysociety.org.uk/sites/default/files/attachments/Chapter08Verity2015.pdf
https://www.sciencedirect.com/topics/medicine-and-dentistry/convulsion
https://jamanetwork.com/journals/jamapediatrics/fullarticle/495848
https://www.sciencedirect.com/topics/medicine-and-dentistry/convulsion