EM Monthly Quiz: Sizing up a seizure

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What’s your first test in examining this female patient?

A 23-year-old obese female patient with a history of irregular menses presents to the ED after suffering a witnessed generalized seizure.  Her companions report that she was acting normally just before the seizure occurred. Point of care glucose obtained by EMS was 89, and she is now recovering slowly upon arrival to the ED.

Vital signs are HR 103, BP 140/76, RR 16, SpO2 98% (room-air), T 37.1°C (98.8°F).  On examination, she is mildly somnolent, but is easily roused to verbal stimuli and answers questions appropriately.  Her neurologic examination is unremarkable. She has never had a previous seizure.  What is the first test that should be performed on this patient?


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  1. Alcohol level
  2. Electroencephalogram (EEG)
  3. Lumbar puncture
  4. Magnetic resonance imaging (MRI)
  5. Pregnancy test

Correct answer:

E. Pregnancy test

A pregnancy test is the most important test that should be obtained in the ED for this patient.  Preeclampsia/eclampsia is a true medical emergency, and should be ruled-out for any child-bearing age female who presents with a seizure episode.


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Additionally, the American College of Emergency Physicians (ACEP) recommends obtaining a sodium level on seizure patients to rule-out hyponatremia as an acute cause.  See the below chart for seizure differentials that should be considered.

Incorrect answer choices:

Alcohol level (Choice A) is not indicated in this case.  The patient has an appropriate neurologic examination, and there is no evidence of intoxication. Alcohol withdrawal can cause seizures, but a low alcohol level does not diagnose alcohol withdrawal. Therefore, this test is not necessary.

EEG (Choice B) is a reasonable test that should be obtained as an outpatient, but is not necessary while the patient is in the emergency department.  If she has recurrent seizure episodes, or is found to be in status epilepticus, she should be admitted to the hospital for continuous EEG testing.


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Lumbar puncture (Choice C) should only be performed if the patient has focal neurologic findings, is immunocompromised, or has evidence of meningitis or other CNS infection. She has an exam that is appropriate for postictal status and is afebrile.

MRI (Choice D) would also be indicated in a patient who does not return to baseline, or a patient who requires hospital admission for status.  Head CT should be considered in the ED for all patients with new onset seizure; however, if it can reasonably obtained as an outpatient and the patient has rapidly returned to their baseline status, it is reasonable to perform the head CT as an outpatient.

EM Coach_EP Monthly Option 3 (December 2019)

References:

Kornegay JG. Ch 171: Seizures in Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.

Clinical policy. Annals of Emergency Medicine. 2004;43(5):605-625. doi:10.1016/j.annemergmed.2004.01.017

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