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

> A neurology emergency case for medical students: a 32-year-old brought in still fitting. First steps, what to ask the witness, red flags, the first tests and the causes to look for.

- Neurology · Intermediate · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/32-year-old-man-brought-in-fitting
- Work up this patient: https://www.medikarya.in/case-studies/32-year-old-man-brought-in-fitting

## How the patient presents

His brother brought him in by ambulance, still jerking and not waking up. His brother tells you what he knows.

## 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.

### In the brain

- Meningitis or encephalitis
- Neurocysticercosis
- Head injury
- Stroke
- Tumour

### Metabolic

- Hypoglycaemia
- Low sodium
- Low calcium

### Toxic

- Alcohol withdrawal
- Drug overdose
- Poisoning

### Epilepsy

- Known epilepsy with missed medicines or a trigger

### Mimics

- Non-epileptic attack
- Faint with jerking

## 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.

---

A study guide for medical students, not medical advice. Follow your institution's protocols in practice.