Some ED seizure patients should get immediate CT
If a seizure patient comes to your ED, one of the first questions you need answered is "What diagnostic testing is needed?"
"I think there is some confusion on who needs it emergently. An immediate CT scan could affect a patient's outcome with hemorrhage, so a decision can be made about emergent neurosurgical intervention," says Donna Avanecean, RN, FNP-C,CNRN, a nurse practitioner in the Stroke Center at Hartford (CT) Hospital.
Prompt imaging is needed for seizure patients with an abnormal neurological examination, focal seizure onset, history of AIDS, and infants younger than six months, according to new guidelines from the American Academy of Neurology.1 "The recommendations for when to order imaging are very useful," says Avanecean. "The one question that always comes up in the need for patients presenting with seizures is what imaging is necessary."
An initial noncontrast CT allows you to rule out the obvious reasons for seizure such as hemorrhage, tumor, or other mass occupying lesion, says Avanecean.
Obtaining a thorough history is important and may help guide diagnostic tests, says Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain, & Spine Center at Brackenridge Hospital in Austin, TX. Brandt recommends you ask patients the following: Is this the first seizure? How long has it lasted? Was there anything that preceded it, such as hallucinations, smells, or visual changes? Seizures can present in multiple different ways, not just the classic "tonic-clonic" type, she says. In partial seizures, the patient may not have impaired consciousness, and the seizure itself manifests itself with local extremity jerking, head turning, and emotional disturbances, she says. "Generalized seizures can be the classic tonic-clonic movements, but may also show as absence seizures," says Brandt. "The patient has a momentary lapse of awareness and all ongoing activity stops until the seizure stops."
Patients may present with atonic seizures, involving a sudden loss of muscle tone and the patient dropping to the floor, says Brandt. "Immediate diagnostic tests are especially important in new onset of seizures, if they are prolonged, if the seizure type has changed from typical seizure presentation, or if there is a suspected injury due to the seizure," she adds.
- Harden CL, Huff JS, Schwartz TH, et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 69:1,772-1,780.