Brought in fitting, a 32-year-old: a seizure emergency to work up

Why a prolonged seizure matters

A seizure that keeps going is an emergency: the longer it lasts, the harder it is to stop and the more harm it does. Treat it step by step on your hospital's protocol while looking for a cause you can fix, such as a low glucose.

What to ask in the history

• When it started, what it looked like, whether he has woken in between
• Previous seizures or epilepsy; medicines and missed doses
• Alcohol: how much, and any recent stopping
• Drugs, possible overdose or poisoning
• Head injury
• Fever, headache, neck stiffness, recent illness
• Diabetes and its treatment
• Other illnesses, including HIV or tuberculosis

Red flags

• Still fitting, or not waking between seizures
• Low oxygen saturation or poor breathing
• Low glucose
• Fever with neck stiffness or a rash
• Head injury
• A first-ever seizure
• Signs on one side of the body

What to examine

• Airway, breathing, circulation; oxygen; protect him from injury
• Bedside glucose
• Observations and temperature
• Injuries, tongue bite
• Neck stiffness, rash
• Pupils, and a neurological examination once the seizure stops
• Signs of alcohol or drug use

First investigations

• Capillary glucose at once
• Blood gas
• Sodium, calcium, magnesium, kidney and liver function
• Full blood count
• Anti-epileptic drug levels
• Toxicology
• CT head
• Lumbar puncture if infection is suspected and it is safe
• EEG if he does not wake up

Differential diagnosis of a prolonged seizure

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Forgetting to check the glucose.
• Giving too little of the first drug, or waiting too long for the next step.
• Stopping once the seizure stops, without looking for the cause.