EPS or seizure

ixchel · Oct 6, 2015

Is this patient on meds that would give them EPS? The best way to know which it was for sure is to get an EEG. Seizures don't always look the way you expect them to. Ativan will help both issues, so that's not much help.

elkpark · Oct 6, 2015

Is this patient on meds that would give them EPS?

This was my immediate thought as well. If there is any question about whether an episode is dystonia or a withdrawal seizure, my first thought would be, well, is the person on meds that can cause dystonia, or is the person withdrawing from EtOH? If he's not on meds that can cause dystonia, you've kinda ruled that out. And, if he's not withdrawing from EtOH, it's not likely that he's having a withdrawal seizure.

There are also just plain, ol' "regular" seizures that people can have on psych units ...

Jules A, MSN · Oct 7, 2015

If the patient was likely withdrawing from ETOH I also would have erred on the side of seizure and given a benzodiazpine rather than anticholinergic.

banana, MD · Nov 4, 2015

An EtOH withdrawal seizure is typically a generalized tonic clonic one, and if the pt remained conscious during this episode with no post-ictal confusion, this points away from this, though as one poster mentioned, in this context it is probably prudent to consider more life threatening things first (i.e., s seizure). In order to have been EPS the patient should have a hx of recent administration of a medication that could cause this, most likely a high-potency first generation antipsychotic (i.e., haldol) which incidentally also lowers the seizure threshold. In either case, a BZ can effectively treat either problem acutely, though for eps anticholinergics are usually thought of first. An EEG would only reveal active seizure activity during a seizure, and recent Ativan administration could actually muck up the EEG and confound this test. On another note, if there was clear potential for secondary gain (shelter, legal troubles, etc...) or primary gain (underlying psychological issues) this may suggest alternate dxs such ad pseudo seizures or malingering

ixchel · Nov 4, 2015

Weird that this post was bumped. We very recently had a patient with what looked like tardive dyskinesia, but had been labeled as seizures by the MDs. Honestly, a seizure will only affect the part of the brain it affects. For some people, that's everything. Then also for some, it's next to nothing. The rest are somewhere in between.

The one thing I have learned concretely is that they frequently will not look the way you expect. For the patient we had, it was night shift when we started talking about whether it's really seizures or not. There was question about possible faking because she did seem to have some motor function and awareness, and rapid to no postictal periods. We talked about psych meds, medical history, basically all that's been mentioned here. In the end, we had more questions than we started with.

It would be worth noting that I have epilepsy, diagnosed only a few years ago. The reason for that - I remain fully functional when I have them. Now, if I go into status epilepticus, I do have cognitive impairment. But, that has not happened since the episode that led to my diagnosis. Other things I experience are random olfactory hallucinations and nominal aphasia. I know I'm having seizure activity while I'm sleeping when those start happening during the day. My seizures are in my left temporal lobe.

I share that anecdotally mostly to say - give patients a good shot at an accurate diagnosis. Sometimes we are blinded by the "nursing judgment" of those giving us report. Look at it with fresh eyes, and know that even if the patient is faking, she may actually believe it's real. Until you KNOW they are faking, it's important to proceed as though they are not. I was told by THREE of my care providers that my problem was anxiety. If I didn't absolutely insist I get a neuro referral, I imagine that would give this story a very different ending.

blackribbon · Dec 25, 2015

Okay...I wouldn't have suspected EPS if the patient wasn't on psych meds that had that potential side effect. This was a psych unit where every patient has prn Haldol at the very least. He was also on librium treatment because of his known alcohol history. Also, a ETOH seizure isn't the same as an epileptic one, is it? He stopped seizing when he was given IV ativan....which is the purpose of ativan's use when CIWAing a patient. I recently did a shift with one of the nurses on that unit who was working with me that night. She verified that he was diagnosed to be in DTs so my nursing gut was right.

Davey Do · Dec 26, 2015

In working chemical dependency treatment back in the '80's, I never saw an alcohol withdraw seizure. However, the MD, an Internist board-certified in addictionology, prescribed librium 50 mg q hr prn s/sx withdrawal.

When I first learned of the whopping dose of librium, in orientation, I was dumbfounded. But then again, like I said, I never saw an alcohol withdrawal seizure wile working CD tx. And, in reading your post, blackribbon, I considered that perhaps the administration of another benzo did the trick for your pt.

Having been out of CD tx for so long, and not dealing a lot with hardcore Alcoholics, your thread is a good learning situation for me! Thanks!

ixchel · Dec 26, 2015

Also, a ETOH seizure isn't the same as an epileptic one, is it?

It has different etiology, but in the end, it's still a seizure. Sort of like... If a person has primary hypertension, and another has it secondary to anxiety, does it change the reading on the BP machine, or the potential damage it could do if left untreated over time? Where the seizures differ is in knowing one will hopefully stop after withdrawal ends, and the other is lifelong. Both types of seizures should be able to be stopped with benzos, just as both types of hypertension may be temporarily relieved with hydralazine.

Davey, I've had only one patient who did seize from DTs, and it was not on my shift. He also stopped protecting his own airway. He was intubated for quite some time, until the maxed out sedatives stopped working effectively and he extubated himself. He spent several days being violent toward staff and no amount of haldol or lorazepam would slow him down. This guy was massive and scary. When he finally came out of the woods, he was as nice as could be, apologetic, and terrified of all of the work sobriety would require.