Seizures are a common neurological emergency that we frequently encounter in the emergency department (ED). Their sudden onset can be distressing for both patients and their families, necessitating prompt and effective management. In Ghana, the challenges in diagnosing and treating seizures are compounded by limited resources and varying levels of healthcare access. This blog post delves into the intricacies of seizure management in the ED, illustrated by a realistic case scenario, and offers insights into best practices for emergency physicians in Ghana.
Case Scenario: A Day in the ED
It’s a typical busy afternoon in the ED when a 28-year-old man, Kofi, is rushed in by his family. He was reportedly working on his farm when he suddenly fell to the ground, convulsing violently. His family is understandably frantic and worried.
Upon arrival, Kofi is in the postictal state—confused, drowsy, and unaware of his surroundings. His vitals are checked: blood pressure is 130/85 mmHg, heart rate 100 beats per minute, respiratory rate 22 breaths per minute, and oxygen saturation is 98% on room air. A quick assessment reveals no immediate life-threatening injuries, and a full set of vitals is stable.
Initial Assessment and Management
The first step in managing Kofi’s seizure is to ensure his airway is clear and to maintain adequate ventilation and circulation. This initial ABC (Airway, Breathing, Circulation) approach is crucial in preventing further complications.
1. Airway and Breathing: Kofi’s airway is patent, but suctioning is performed to clear any secretions. He’s positioned on his side to prevent aspiration, a common risk in postictal patients. Oxygen is administered via a face mask to ensure adequate oxygenation.
2. Circulation: An intravenous (IV) line is established for potential medication administration and fluid resuscitation if necessary. Blood is drawn for laboratory tests, including electrolytes, glucose, calcium, magnesium, renal function tests, and a complete blood count.
3. Detailed History and Physical Examination: As Kofi begins to regain consciousness, a detailed history is obtained from his family. They report that Kofi has had no prior history of seizures, is not on any medication, and has no known chronic illnesses. They also mention that he has been working long hours in the heat, which raises concerns about potential electrolyte imbalances or dehydration.
A thorough physical examination is performed to look for any signs of trauma, focal neurological deficits, or other underlying causes of the seizure.
Investigations and Differential Diagnosis
With the initial stabilization complete, the focus shifts to determining the cause of Kofi’s seizure. Seizures can result from various etiologies, including metabolic disturbances, structural brain abnormalities, infections, toxins, and idiopathic causes. The following investigations are pivotal:
1. Laboratory Tests:
- Blood glucose: Hypoglycemia is a common reversible cause of seizures.
- Electrolytes: Sodium, potassium, calcium, and magnesium imbalances can trigger seizures.
- Renal function tests: Uremia due to renal failure is another potential cause.
- Toxicology screen: To rule out substance abuse or poisoning.
2. Imaging: If Kofi’s initial blood work is unremarkable, a non-contrast CT scan of the head may be warranted to exclude structural causes such as a brain tumor, hemorrhage, or infarction.
3. Lumbar Puncture: In cases where infection is suspected (e.g., meningitis or encephalitis), a lumbar puncture may be performed to analyze cerebrospinal fluid.
Management and Treatment
Based on Kofi’s history, examination, and preliminary test results, the most likely cause of his seizure is dehydration and electrolyte imbalance due to prolonged exposure to heat and physical exertion.
1. Rehydration and Electrolyte Correction: IV fluids are administered to correct dehydration, and any identified electrolyte imbalances are addressed. For instance, if hyponatremia is detected, careful correction with saline is initiated.
2. Antiepileptic Medications: If Kofi experiences recurrent seizures or does not return to baseline mental status, antiepileptic drugs (AEDs) may be necessary. In the ED, benzodiazepines like lorazepam or diazepam are commonly used for immediate seizure control. If further seizures occur, a loading dose of phenytoin or levetiracetam can be given.
3. Monitoring and Support: Continuous monitoring of Kofi’s vitals and neurological status is essential. Any signs of recurrent seizures or complications are promptly addressed.
Disposition and Follow-Up
Once Kofi is stabilized and no immediate life-threatening causes are identified, the decision on his disposition is made. In Ghana, the availability of resources and access to neurology specialists can influence this decision.
1. Admission: Kofi may require admission if:
- He has recurrent seizures or status epilepticus.
- There are significant electrolyte imbalances needing correction.
- There are concerns about his ability to be safely monitored at home.
2. Discharge: If Kofi remains seizure-free and has no significant abnormalities in his investigations, he may be discharged with:
- Clear instructions on hydration and avoiding excessive physical exertion.
- Education on seizure precautions (e.g., avoiding activities like swimming or operating heavy machinery until cleared by a doctor).
- A follow-up appointment with a neurologist or general physician for further evaluation and possible initiation of long-term AEDs if indicated.
Conclusion
Managing seizures in the emergency department requires a systematic and thorough approach, especially in resource-limited settings like Ghana. By focusing on initial stabilization, identifying the underlying cause, and providing appropriate treatment, emergency physicians can significantly impact patient outcomes. Kofi’s case highlights the importance of considering common etiologies like dehydration and electrolyte imbalances, particularly in our climate and working conditions. Continuous education and training in seizure management are vital for improving the quality of care provided to our patients.
