A few limb jerks during a syncopal event are present in approximately 90 percent of witnessed syncopal episodes, as lack of blood perfusion to the brain causes anoxic neuronal irritation. 6 Increased muscle tone during the event suggests seizure while decreased muscle tone during the event suggests syncope.Īnother common pitfall is to assume seizure when there are any number of limb-jerking movements witnessed. Loss of consciousness with prolonged sitting or standing has a specificity of 98 percent and +LR 20 for syncope, while dyspnea and palpitations before loss of consciousness have a specificity of 98 percent and 96 percent and +LR of 13 and 8.3 respectively. On the flip side, several clinical findings make syncope much more likely than seizure for the patient who has lost consciousness. Hence, one can ostensibly rule out syncope by ruling in seizure using these clinical features. 6,8 One explanation for this is that the tongue often deviates laterally during a tonic-clonic seizure. 6,7 On physical examination, evidence of a tongue laceration has a specificity of 97 percent and +LR of 17, and even better, evidence of a lateral tongue laceration has a specificity of 100 percent for tonic-clonic seizure, essentially clinching the diagnosis. Even though one review found that the specificity of urinary incontinence is 96 percent with a +LR 6.7 for seizure, urinary incontinence has subsequently been found unreliable in distinguishing syncope from seizure. One common clinical pitfall is assuming the presence of seizure when urinary incontinence occurs during the event. 6 The absence of presyncope has a specificity of 86 percent and +LR of 5.6 while postictal state is present in 96 percent of patients with seizures. Witnessed head turning during the event has a specificity of 97 percent and +LR of 14 for seizure, while unusual posturing during the event has a specificity of 97 percent and a +LR of 13. If one can accumulate enough accurate clinical findings of seizure, syncope can essentially be ruled out. There are several clinical findings with impressive specificities and likelihood ratios (LR) to help distinguish syncope from seizure. The first step in the evaluation of syncope is to distinguish it from seizure. 5 Step 1: Distinguish Syncope from Seizure The most recent ACEP Clinical Policy on Syncope state that history, physical examination, and ECG are the only level A recommendations for the evaluation of syncope. 2,3,4 One of the problems with indiscriminate ordering of tests for patients who present with syncope is that it may diminish our efforts in taking a thorough history and performing a thoughtful physical examination-the very areas that we should be concentrating our energies. 1 When it comes to the assessment and workup of patients who present to the ED with syncope, advanced imaging, such as head CT, has very low diagnostic yield. ![]() The last two decades have seen ever-increasing utilization of diagnostic testing in emergency departments (EDs) across the United States. Best Practices for Seizure Management In the Emergency DepartmentĮxplore This Issue ACEP Now: Vol 42 – No 01 – January 2023.Pulmonary Emboli May Be an Under-Recognized Cause of Syncope.New “FAINT” Score May Work for Syncope Risk Stratification, but Needs Validation.Regardless of etiology, a seizure diagnosis severely limits a patient's driving privileges, although laws vary by state. ![]() Treatment with antiepileptic medications reduces the one- to two-year risk of recurrent seizures but does not reduce the long-term risk of recurrence and does not affect remission rates. Patients with a normal neurologic examination, normal test results, and no structural brain disease do not require hospitalization or antiepileptic medications. ![]() ![]() The most common laboratory findings associated with a seizure are abnormal sodium and glucose levels. Magnetic resonance imaging is preferred over computed tomography except when acute intracranial bleeding is suspected. Neuroimaging also should be performed in children with risk factors such as head trauma, focal neurologic deficits, or a history of malignancy. Electroencephalography is recommended for patients presenting with a first seizure, and neuroimaging is recommended for adults. No single sign, symptom, or test clearly differentiates a seizure from a nonseizure event (e.g., syncope, pseudoseizure). The patient history and physical examination should direct the type and timing of laboratory and imaging studies. Seizure is a common presentation in the emergency care setting, and new-onset epilepsy is the most common cause of unprovoked seizures.
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