Anecdote 1:Don’t call it a seizure, start CPR
Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure!
You: That is not a seizure, let’s start CPR!
(the patient survives, and receives emergent catheterization opening a blocked vessel)
Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite Sam, etc. If the setting is more appropriate for cardiac arrest, check pulses first.
This is probably not substantially different from convulsive syncope but I will describe that separately:
Anecdote 2: Don’t call it a seizure, refer to cardiology
“we never figured out why the Brugada syndrome patient had a seizure” –someone who should know better
Blood bank studies show that about 10% of syncope events are accompanied by a convulsion. These can look like epileptic generalized tonic clonic seizures. The differences are:
Pre-ictal: what were the setting, the symptoms, and the signs, before the event. An aura suggests a seizure. Standing in church suggests syncope. Alcohol withdrawal suggests seizure, etc.
Ictal: convulsive syncope is less rhythmic, less symmetrical, and less sustained
Post-ictal: Convulsive syncope patients regain normal arousal within a minute, seizure patients take 10-15 minutes
It isn’t a seizure until you have a diagnosis. It is a convulsion. Apply an appropriate differential that includes convulsive syncope.
Ancedote 3: Don’t call it a seizure, check the temperature
A middle aged patient is waiting to be seen for generalized weakness. The triage RN rushes them out of the waiting room because of a “seizure.” He never lost consciousness and was awake the entire time. Temp is 103 oral. You ultimately diagnose sepsis from pyelonephritis.
Rigors can cause tremendous shaking and can make us worry about seizure. Obviously a seizure can raise the temperature so judgment is required. But don’t automatically assume that a convulsion from sepsis is a seizure. Rigors happen when the temperature is rising, so recheck the temperature.
Anecdote 4: Don’t call it a seizure, educate the family
A patient is here for opioids. The doctor said no. She has a history of developing “seizures” when she does not get narcotics. Now she is screaming loudly and, wait for it…. The RN runs to you announcing a seizure and asks if you will give Ativan. Okay, I admit it, I often give Ativan if I am not sure. One time I went to the patient and said “really, you are having a seizure? Can I see the tongue biting, show me the tongue” and she proceeded to show me her teeth, biting the tongue.
This is tough. Don’t expect the family to understand the difference between seizures and psychogenic convulsions (also known as pseudoseizure). Educate them on the potential for psychogenic causes (but don’t prematurely rule out epilepsy either, unless it is abundantly obvious)
TAKE HOME POINTS:
-Our terminology can box us in. Don’t call it a seizure unless you are committing to an epileptic etiology.
-Ask about circumstances before, during, and after the event to identify possible convulsive syncope