Pseudo vs real seizure

If you’ve worked in the emergency department for a few years, you will have seen a pseudo-seizure and hopefully have picked it. I know I was terrified of these in the early days, as I had trouble making the diagnosis and I had seen neurologists get it wrong. Now, they are a little easier to pick.
I’m not one to do prolactin levels and blood gases in this group, although I do look at pulse oximetry, which should show a decreased oxygen saturation, during a real seizure.
Here are some other tips that might help you. Be careful as there are always exceptions and always err on the side of giving your patient the benefit of the doubt.

I look for seven things.  Sure, the history and everything that has occurred around the event, has to make sense etc. But if I’m unsure, this is what I use. You may have more tips. Let me know.

1. The seizure lasts longer than most normal seizures ie., 5 minutes vs 1 – 2 minutes.
2. There is a very brief ie., one to five minutes post ictal period.
3. The patient pay be awake post seizure, but not communicating (beware ‘Locked-in’ syndrome).
4. The patient remembers all events that occurred during a generalised tonic clonic seizure.
5. There is forward pelvic thrusting during the seizure- very indicative.
6. There is turning of the head from side to side during the seizure.
7. There are asynchronous limb movements during the seizure.

OK, you’ve made the diagnosis, now the way you handle it with the patient, is important. Some patients need to simply be asked to stop. Whatever approach you take, it shouldn’t be threatening, but one that tells the patient you realise they are under great stress and to invite an open discussion, so you can assist them. Psychiatric review will of course be required.