Emory Neurology · PGY2 Bootcamp
Prepared by Erafat D. Rehim, MD | Emory Neurology
Seizures for PGY2 Neurology.
First decisions
1
Is the patient actively seizing?
If yes, treat as status when ≥ 5 min or recurrent without recovery. ABCs, lateral position, O₂, glucose, IV/IO, monitors, call help, give a full-dose benzodiazepine when indicated.
2
Reverse what's reversible.
Glucose · Na · O₂ · toxins/withdrawal · infection · pregnancy/eclampsia · trauma · stroke. Treat the cause, not just the seizure.
3
Reconstruct the event.
Before · Beginning · During · After · Context · Evidence. Ask for a phone video. Never diagnose from "shaking."
4
Was this even epileptic?
Differential: syncope, cardiac arrhythmia, functional seizure, migraine, movement disorder, sleep, intoxication. ECG always.
| Clue | Epileptic seizure | Syncope | Functional seizure |
|---|---|---|---|
| Before | Aura, sleep, missed meds, focal onset | Standing, pain, heat, prodrome, palpitations | Often context-linked; may build gradually |
| During | Stereotyped tonic-clonic or focal signs; tongue bite | Brief LOC; pallor; a few myoclonic jerks can occur | Long, fluctuating, asynchronous; eyes often closed |
| After | Postictal confusion, aphasia, focal deficit possible | Rapid orientation when supine | Variable recovery; recall may be preserved |
| Test | EEG/MRI support risk and classification | ECG always; orthostatics/telemetry as story fits | Video EEG when uncertain; diagnose positively |
5
Does it meet epilepsy criteria?
ILAE: 2 unprovoked seizures > 24 hr apart · 1 unprovoked + ≥ 60% 10-yr recurrence · epilepsy syndrome.
Avoid harm
6
Classify enough to avoid harm.
Focal · Generalized · Unknown. Look for absence or myoclonus before choosing meds. Wrong med can worsen the syndrome.
7
Don't misuse EEG.
Helpful when positive. A normal EEG does not exclude epilepsy.
8
Medication map.
Focal: lamotrigine / levetiracetam. GTC: lamotrigine / levetiracetam / valproate. Absence only: ethosuximide. Myoclonic / JME: levetiracetam / valproate. Avoid carbamazepine · oxcarbazepine · phenytoin · gabapentin · pregabalin in absence/myoclonic.
9
Don't discharge without DRIVE SAFE.
Driving · Rescue med · Injury prevention · Valproate/pregnancy · EEG/MRI/neurology · SUDEP · Adherence · First aid · Emergency return. GA: 6 mo seizure-free; reporting not mandatory.
10
After 2 failed appropriate meds → refer.
Drug-resistant epilepsy = ILAE definition. Next prescription is a comprehensive epilepsy center, not drug #3.
Status epilepticus is a clock problem.
0 min
ABCs · IV · O₂5 min
Benzo full dose10 min
Repeat benzo20 min
2nd-line ASM40 min
ICU · anesthesia| Wt | LEV 60 mg/kg | VPA 40 mg/kg | fPHT 20 mg PE/kg |
|---|---|---|---|
| 50 kg | 3 g | 2 g | 1000 mg PE |
| 60 kg | 3.6 g | 2.4 g | 1200 mg PE |
| 70 kg | 4.2 g | 2.8 g | 1400 mg PE |
| 80 kg+ | 4.5 g cap | 3 g cap | 1500 mg PE cap |
Use local protocol and patient context. Avoid valproate in severe liver disease; avoid fosphenytoin when conduction toxicity is a concern.
Words for functional seizures.
"Your events are real and treatable. They are not caused by the electrical seizures we treat with antiseizure drugs, so those drugs are unlikely to help. The next step is a treatment plan targeted to functional seizures."
Resource: UAB/ReACT FND Health offers ReACT, a research-supported treatment for FND/functional seizures. Introduce it as skills-based therapy that retrains control over involuntary symptoms, not as "it is just stress." Appointment/info: reactfnd.health · 205-235-2010.