Model Answer
0 min readIntroduction
Recurrent seizures in a young adult represent a significant medical emergency requiring prompt and accurate diagnosis and management. Seizures are transient disturbances of brain function caused by abnormal excessive or synchronous neuronal activity. The etiology can range from structural brain lesions to metabolic disturbances or genetic predispositions. A thorough clinical assessment, coupled with appropriate investigations, is crucial to identify the underlying cause and initiate targeted therapy. Effective emergency management aims to terminate the seizure, prevent complications, and stabilize the patient.
(i) Clinical History and Examination
A detailed history and neurological examination are paramount. Key points to elicit in the history include:
- Seizure Characteristics: Detailed description of the seizures – onset (focal vs. generalized), duration, frequency, aura (if any), associated symptoms (tongue biting, urinary incontinence, postictal confusion).
- Past Medical History: Previous seizures, head trauma, neuroinfections (meningitis, encephalitis), stroke, congenital neurological disorders, systemic illnesses (diabetes, hypertension, renal failure).
- Medication History: Current medications, including over-the-counter drugs and herbal remedies, as some can lower the seizure threshold.
- Family History: Family history of seizures or epilepsy.
- Social History: Alcohol or drug abuse, sleep deprivation, recent travel.
The neurological examination should focus on:
- Mental Status: Level of consciousness, orientation, memory.
- Cranial Nerves: Assess for any deficits.
- Motor Function: Strength, tone, reflexes, coordination.
- Sensory Function: Light touch, pain, temperature, proprioception.
- Fundoscopy: To rule out papilledema (suggesting increased intracranial pressure).
- Signs of Meningeal Irritation: Nuchal rigidity, Kernig’s sign, Brudzinski’s sign.
- Focal Neurological Deficits: Weakness, sensory loss, aphasia, visual field defects – these suggest a structural lesion.
(ii) Investigations
Investigations are crucial to determine the etiology of the seizures. The following are warranted:
- Complete Blood Count (CBC): To rule out infection or anemia.
- Electrolytes, Blood Urea Nitrogen (BUN), Creatinine, Glucose, Calcium, Magnesium, Phosphate: To identify metabolic disturbances.
- Liver Function Tests (LFTs): To assess liver function.
- Toxicology Screen: To detect drug or alcohol abuse.
- Electroencephalogram (EEG): Essential for confirming the diagnosis of epilepsy and characterizing the seizure type. Continuous EEG monitoring may be needed for frequent or prolonged seizures.
- Neuroimaging:
- Computed Tomography (CT) Scan of the Brain: Rapidly identifies structural lesions like hemorrhage, mass lesions, or stroke.
- Magnetic Resonance Imaging (MRI) of the Brain: More sensitive than CT for detecting subtle structural abnormalities, particularly in the temporal lobe.
- Lumbar Puncture (LP): If meningitis or encephalitis is suspected, especially if there are signs of meningeal irritation.
(iii) Emergency Management
The steps in the management of a patient presenting with recurrent seizures in the emergency department are:
- Ensure Airway, Breathing, and Circulation (ABC): Protect the airway, administer oxygen, and monitor vital signs.
- Terminate the Seizure:
- First-line: Benzodiazepines (Lorazepam 0.1 mg/kg IV, Diazepam 0.2 mg/kg IV/IM).
- Second-line (if benzodiazepines fail): Phenytoin 20 mg/kg IV (slowly), Phenobarbital 20 mg/kg IV (slowly), or Levetiracetam 20-60 mg/kg IV.
- Monitor Vital Signs: Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation.
- Establish IV Access: For medication administration and fluid resuscitation.
- Check Blood Glucose: Administer glucose if hypoglycemic.
- Identify and Treat Underlying Cause: Address any metabolic disturbances, infections, or toxic exposures.
- Postictal Care: Monitor for postictal confusion, respiratory depression, and aspiration.
- Consider Admission: For further evaluation and management, especially if the seizures are refractory to treatment or the etiology is unclear.
(iv) Common Diseases Manifesting with Recurrent Seizures
Several diseases can present with recurrent seizures. Three common examples are:
- Epilepsy: A chronic neurological disorder characterized by recurrent, unprovoked seizures. Various types exist, including generalized and focal epilepsy.
- Brain Tumor: Tumors can cause seizures by directly irritating the brain tissue or by causing edema and increased intracranial pressure.
- Stroke: Both ischemic and hemorrhagic strokes can lead to seizures, particularly in the acute phase.
Conclusion
Managing a young adult with recurrent seizures requires a systematic approach encompassing a thorough clinical evaluation, appropriate investigations, and prompt emergency management. Identifying and addressing the underlying etiology is crucial for long-term control. While benzodiazepines are the first-line treatment for acute seizures, a comprehensive diagnostic workup is essential to guide further management and prevent future episodes. Early recognition and intervention can significantly improve patient outcomes.
Answer Length
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