Snapshot A 78-year-old man presents to the emergency department for a headache. He is accompanied by his wife who reports that his headache progressively worsened over the course of weeks. He does not have a history of headaches. Physical examination is normal. A CT head without contrast demonstrates subdural hematomas. Neurosurgery was consulted and determined that the intracranial bleeds were stable but he was admitted to the hospital due to confusion in the setting of a newly found urinary tract infection. After a few days of admission, he had a witnessed generalized-tonic clonic seizure, prompting him to being treated with benzodiazepines. Introduction Definition a seizure presentation characterized by body stiffening (tonic) and rhythmic jerking (clonic) movements Etiology Can begin as a partial seizure that secondarily generalizes Bilateral hemispheric seizures Presentation Symptoms/physical exam tonic phase login to view 4 more bullets clonic phase login to view 1 more bullet these seizures typically last 1-3 minutes and the patient subsequently becomes confused and drowsy (post-ictal) Imaging MRI brain with and without contrast indication login to view 1 more bullet Studies Patients presenting with a first-time seizure should be evaluated with serum electrolytes, complete blood count, glucose, and a urine toxicology screen prior to further testing Electroencephalogram indication login to view 1 more bullet Lactate elevated due to muscle contraction => self-resolves Differential Psychogenic nonepileptic seizures (PNES) differentiating factors login to view 3 more bullets Migraine with aura differentiating factors login to view 1 more bullet Treatment Medical antiepileptic drugs (AED) login to view 4 more bullets corticotropin (ACTH) login to view 1 more bullet Complications Behavioral and cognitive alterations Aspiration Head strike