Not all SEIZURES are the same!

We see them all the time in the ED... but here are a few to remember when the patient isn't the classic... "I forgot to pick up my refills" seizure/status epilepticus case

- Josh

1/7

Withdrawal Seizure

Patho: regulation of synaptic GABA r.
Tx: BZDs, phenobarbital, propofol (in this order)

evidence to support use of non-GABAergic (levetiracetam, CBZ, phenytoin, etc)
Phenytoin vs placebo RCT = no difference

PMID:[2024792][16372057]

2/7

Eclamptic Seizure

Tx: MgSO4 4-6g IV over 15-20min
- if no IV access, 5g IM each buttock (ouch)

BZD/phenytoin if Mg++ is contraindicated (ex: myasthenia gravis)
~80% of eclamptic seizures preceded by severe HA, blurred vision, photophobia, AMS

PMID:[30575675]

3/7

Isoniazid-induced Seizure

Patho: INH decreases GABA lvls & causes lactic acidosis
Pyridoxine (vit. B6) is a co-factor for GABA synthesis

Tx: Pyridoxine 1g IV for each g of INH
1g over 1 min; repeat Q 5-10 min until seizure [Max = 5g]

PMID:[29397257]

4/7

Hyponatremia-induced Seizure

Etiology: Multifactorial, risk when serum Na+ < 120 mEq/L
for diuretics, SSRIs, CBZ, DDVAP

Tx: Hypertonic saline (3%)
Target 6-8 but < 12mEq/L in 24 hr & < 18mEq/L in 48 hr
Faster repletion can cause ODS

PMID:[25822386]

5/7

Hypoglycemia & Seizures

Tx: Fix BG 50-100mL D50%W, glucagon

"Kitchen Sink" for refractory cases
IV hydrocortisone induce peripheral insulin resistance
Octreotide 50-100mcg Q6H if sulfonylurea overdose
Supplemental K+ in insulin/SU overdose

PMID:[29316226]

6/7

Bottom Line:
A good hx & peak into the pt's med-profile may help u identify a precipitating drug/etiology of the seizure
Not all seizures are the same

What interesting cases have u encountered in practice Please share

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