Intracranial Hemorrhage

Hemorrhagic stroke (or intracranial bleeding from trauma) may predispose a patient to seizures. Larger bleeds causing mass effect are at higher risk, while deep, small intraparenchymal bleeds that do not involve the temporal regions are considered low risk. Common practice is to give a prophylactic loading dose of phenytoin or fosphenytoin.

Trauma

Four percent of epilepsy is caused by trauma. The risk of post-traumatic seizures is directly related to the severity of injury, but is not affected by early use of antiepileptic medication.^10,11

Alcohol Withdrawal

Seizures caused by alcohol withdrawal classically occur 6-48 hours after cessation of drinking and can occur at any blood alcohol level.

Large doses of benzodiazepines, and occasionally phenobarbital as a second-line agent, may be necessary to prevent or control seizures. Interestingly, one study found a benefit to giving benzodiazepines to alcoholic patients who presented to the emergency department with a complaint of seizures even if they were not actively seizing.¹²

Toxin-Induced Seizures

In general, the underlying principle is to maximize benzodiazepines, then consider phenobarbital over phenytoin as a second-line agent. Specific treatments include:

• Isoniazid – pyridoxine
• Tricyclic antidepressants – alkalinize the urine, hemodialysis
• Buproprion – hemodialysis
• Lithium – hemodialysis
• Aspirin – alkalinize the urine, hemodialysis

For those patients who present to the emergency department actively seizing, address the ABCs by administering supplemental oxygen and observing for cyanosis, establish IV access, remove tight clothing, determine blood glucose level, and initiate drug therapy to help control the seizure activity. Benzodiazepines are given acutely, but most seizures are isolated and self-limiting.

Status Epilepticus

The newer definition of status epilepticus came about from data that seizure activity is largely bimodal, lasting less than 5 minutes or approximately 30 minutes.¹³ In animal models, irreversible neuronal damage starts as early as 20 minutes to 1 hour of continuous seizures. The goal is to control the seizure before neuronal injury occurs, theoretically between 20 and 60 minutes.