What is the initial workup and treatment for a patient presenting with seizures?

From the Guidelines

The initial workup for a patient presenting with seizures should include a thorough history, physical examination, basic laboratory tests, and neuroimaging, with the goal of stabilizing the patient and identifying the underlying cause of the seizure. The most recent and highest quality study, 1, published in 2024, emphasizes the importance of early treatment and cessation of status epilepticus to reduce morbidity and mortality.

Initial Assessment and Stabilization

The initial assessment should focus on stabilizing the patient by ensuring airway, breathing, and circulation are intact. Obtain vital signs, glucose level, and basic labs including complete blood count, comprehensive metabolic panel, calcium, magnesium, and toxicology screen.

Neuroimaging and EEG

An electroencephalogram (EEG) should be performed to detect abnormal brain electrical activity, and neuroimaging with CT or MRI is essential to rule out structural abnormalities, as recommended by 1.

Acute Seizure Management

For acute seizure management, administer benzodiazepines: lorazepam 4mg IV (or 0.1mg/kg), diazepam 10mg IV (or 0.2mg/kg), or midazolam 10mg IM (0.2mg/kg). If seizures persist beyond 5 minutes or recur, this constitutes status epilepticus requiring additional treatment with fosphenytoin 20mg PE/kg IV at 150mg/min, valproate 40mg/kg IV over 10 minutes, or levetiracetam 60mg/kg IV (max 4500mg) over 15 minutes, as suggested by 1 and 1.

Long-term Management

For long-term management, first-line antiepileptic drugs include levetiracetam 500mg twice daily (titrate to 1000-3000mg/day), lamotrigine (start 25mg daily, titrate slowly to 100-400mg/day), or carbamazepine 200mg twice daily (titrate to 800-1200mg/day), with treatment choice depending on seizure type, patient comorbidities, and potential side effects, as discussed in 1.

Patient Counseling

Patients should be counseled on seizure precautions including driving restrictions, avoiding swimming alone, and medication adherence. Seizures result from abnormal, synchronous electrical discharges in the brain, and antiepileptic medications work by stabilizing neuronal membranes and enhancing inhibitory neurotransmission.

From the FDA Drug Label

The provided drug labels do not directly address the initial workup and treatment for a patient presenting with seizures.

The FDA drug label does not answer the question.

From the Research

Initial Workup for Seizures

The initial workup for a patient presenting with seizures involves a thorough assessment, including:

• Accurate history taking, with active questioning about circumstances of occurrence, clinical manifestations, and postictal symptoms 2
• Physical examination to identify any focal neurologic deficits or signs of structural brain disease
• Laboratory tests, such as serum glucose and electrolyte determination, which are recommended for adults with a first-time seizure, with no comorbidities, and who have returned to a normal baseline 3
• Toxicological screening, which should be performed only in the presence of circumstances suggesting a metabolic or toxic encephalopathy 2

Diagnostic Imaging

Diagnostic imaging, such as:

• Computed Tomography (CT) scan, which is strictly indicated when a severe structural lesion is suspected or when the etiology is unknown 2
• Magnetic Resonance Imaging (MRI), which may not be indicated in the emergency room, but should be preferred to CT as part of the diagnostic assessment 2
• Cranial computerized tomography (CCT), which is useful in selected patients, particularly those with a first-time seizure, recent head trauma, focal neurologic deficit, or focal seizure activity 4

Electroencephalography (EEG)

EEG should be performed within 24 hours after a seizure, particularly in children, and if the EEG is normal during wakefulness, a sleep EEG is recommended 2

• EEG is a necessary extension of the neurologic examination, and most patients also require an MRI scan to identify a potentially epileptogenic lesion 5

Treatment

Treatment of seizures depends on the underlying cause, and may involve:

• Treatment of the cause, in the presence of an acute symptomatic seizure 2
• Symptomatic therapy, which is not justified unless the seizure has the characteristics of status epilepticus 2
• Long-term treatment, which may be considered in patients with abnormal EEG and imaging data, and after consideration of the social, emotional, and personal implications of seizure relapse 2
• Initiation of antiepileptic therapy, which depends on the assessed risk for recurrence, in conjunction with a neurologist consultation 3