Seizures DDx • LITFL • CCC Differential Diagnosis

Overview

Seizures are the manifestation of abnormal hyperexcitable discharges of cortical neurons.
10 minutes of continuous seizure activity is now considered status epilepticus, which may result in neuronal damage. Seizures should be aggressively treated if they last longer than 5 minutes.
International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE) in 2005 definition of epilepsy: brain disorder characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychologic, and social consequences of this condition.
Traditionally, the diagnosis of epilepsy requires the occurrence of at least 2 unprovoked seizures 24 hours apart.

Causes

Epilepsy

May be the first presentation
Noncompliance with anticonvulsant therapy
May be triggered by specific factors, e.g. sleep deprivation, medications (e.g. tramadol, antipsychotics that lower the seizure threshold), intercurrent illness

Other conditions which cause generalized or focal CNS injury can also precipitate or perpetuate seizures

Hypoxia
Metabolic disturbances (e.g. hypoglycaemia, uremia, hepatic encephalopathy)
Electrolyte imbalance (e.g. hyponatraemia, hypernatraemia, hypercalcaemia)
Drug intoxication (e.g. anticonvulsants, antidepressants, antipsychotics, isoniazid, opioids, theophylline, sympathomimetics)
Drug withdrawal (e.g. alcohol, barbiturates, benzodiazepines)
Trauma
CNS neoplasia
Stroke
Intracranial haemorrhage (e.g. subrachnoid hemorrhage, intracerebral hemorrhage)
CNS infection (e.g. meningoencephalitis, cerebral abscess, neurocysticercosis)

Types of seizures

Trieman classification system of status epilepticus

Generalized convulsive SE
Subtle SE (very poor prognosis)
Nonconvulsive SE
Absence SE
Complex partial SE
Simple partial SE

Differential diagnosis of conditions that mimic seizures

Eclampsia
Nonepileptic seizures/ pseudoseizures
Syncope
Acute dystonic reactions
Rigors
Cardiac disorders (e.g. Dysrhythmias, Long QT syndrome, HOCM)

Mnemonics

“SICK DRIFTER”

Substrates (sugar, oxygen)
Isoniazid overdose
Cations (Na, Ca, Mg)
Kids (eclampsia)
Drugs (CRAP: Cocaine, Rum (alcohol), Amphetamines, PCP)
Rum (alcohol withdrawal)
Illnesses (chronic seizure disorder or other chronic disorder)
Fever (meningitis, encephalitis, abscess)
Trauma (epidural, subdural, intraparynchymal hemorrhage)
Extra: toxocologic (TAIL: Theo, ASA, Isoniazid, Lithium) and 3 Anti’s: (Antihistamine overdose, Antidepressant overdose, Anticonvulsants (too high dilanitin, tegretol) or benzo withdrawal.
Rat poison (organophospates poisoning – not actually rat poison!)

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia, HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia, ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

Cite this article as: Chris Nickson, "Seizures DDx," In: LITFL - Life in the FastLane, Accessed on June 2, 2023, https://litfl.com/seizures-ddx/.

Critical Care

Compendium

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Chris Nickson

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

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