Background

Seizures at music festivals are distinct from seizures in the ED in several key ways. Factors such as sleep deprivation, dehydration, strobe lights, and recreational drug use lower attendees’ seizure threshold. True seizures are uncommon, with myoclonic syncope often confused for seizure activity. Seizures are usually generalized and tonic-clonic in nature. Focal seizures are rare and suggest a focal lesion. Unlike the ED, the population attending music festivals is typically young and healthy, without significant comorbidities. Approximately 10% of patients presenting for seizure-like activity at music festivals have a history of a seizure disorder. Seizures in these patients are often a result of missed anti-epileptic medications coupled with the above triggers. Seizures in healthy patients are usually due to recreational substance use; critical substance related causes include cocaine toxicity, alcohol withdrawal, and hyponatremia due to MDMA use.

History

• Type of seizure

• Number of seizures

• Duration of seizures

• Injuries from seizure

• Features of a true seizure

  • Tongue bite

  • Urine incontinence

  • Postictal state

  • Stereotypical movements

• Substance use

• PMHx of seizures and other relevant

  co-morbidities (e.g. diabetes)

Physical Exam

• ABC’s

• Trauma exam

  • Signs of head injury

  • Trauma from fall when seizing

• Neurologic exam

  • Pupils

  • LOC

  • Focal neuro deficits

Management

For the actively seizing patient, refer to the clinical care pathway in Figure 1. Observation on site with appropriate monitoring and resources may be reasonable for patients with a resolved seizure, normal glucose, and normal sodium. In healthy patients with a single generalized tonic-clonic seizure, thought to be related to the above triggers, neuroimaging is often unnecessary. Withdrawal seizures, glycemic derangements, hyponatremia, associated trauma or recurrent seizures require hospital transfer. Patients who fail to return to their neurologic baseline and patients with new focal seizures require neuroimaging and should be transferred. If the patient does not require transfer, monitoring until return to baseline is appropriate, with disposition guided by seizure etiology and assessment of red flags. If the patient has normal vitals, has returned to their neurologic baseline, and there is an identifiable trigger, they may be appropriate for discharge to festival on a case-by-case basis, provided they can be monitored by other festival goers. When discharging seizure patients, provide seizure precaution counseling, especially around driving (transport is often via personal vehicle) and water and recommend they follow up with their family physician.

Figure 1 : Clinical Approach to Patient with Seizure at Music Festivals

Investigations

• Glucose: <4 suspicious for hypoglycemia-induced seizure

• Sodium: <130 suspicious for hyponatremia-induced seizure

  • The ability to check serum sodium is key to avoiding unnecessary transfer.

Differential Diagnosis

• True Seizure

  • Healthy patients: Alcohol withdrawal, MDMA (hyponatremia), hypoglycemia, sympathomimetics, serotonin syndrome

  • Patients with epilepsy: Medication non-adherence, lowered sz threshold

• Myoclonal syncope

  • Most common (~90%)

• Convulsive concussion

• Psychogenic pseudoseizures