What is the step-by-step approach for a neuro exam after a seizure?

Step-by-Step Neurological Examination After a Seizure

A thorough neurological examination should be performed on all patients following a seizure, focusing on identifying the cause, assessing for complications, and determining the need for further management. 1

Initial Assessment (First 5-10 Minutes)

1. Vital Signs and Airway Assessment

   • Check airway patency, breathing pattern, and circulation
   • Monitor blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation
   • Assess for signs of respiratory compromise or aspiration

2. Level of Consciousness

   • Apply AVPU scale (Alert, Voice responsive, Pain responsive, Unresponsive)
   • If not following commands, promptly perform and interpret EEG for diagnosis of seizures 1
   • Consider continuous EEG monitoring for patients who remain altered 1

3. Ongoing Seizure Activity Assessment

   • Observe for subtle ongoing seizure activity (facial twitching, eye deviation, automatisms)
   • Treat clinically apparent seizures immediately 1
   • Consider nonconvulsive status epilepticus in patients with prolonged altered mental status 1

Detailed Neurological Examination (10-30 Minutes)

1. Mental Status Examination

   • Orientation to person, place, time
   • Memory assessment (immediate recall, short-term memory)
   • Language function (comprehension, naming, repetition)
   • Attention and concentration

2. Cranial Nerve Examination

   • Pupillary size, symmetry, and reactivity
   • Extraocular movements and visual fields
   • Facial symmetry and strength
   • Hearing, swallowing, and tongue movement

3. Motor Examination

   • Assess for focal weakness (Todd's paralysis may persist for hours after a seizure)
   • Compare strength bilaterally in upper and lower extremities
   • Check for pronator drift
   • Evaluate tone for rigidity or flaccidity

4. Sensory Examination

   • Test light touch, pain, temperature, and proprioception
   • Compare symmetry between sides
   • Document areas of sensory deficit

5. Coordination and Cerebellar Function

   • Finger-to-nose and heel-to-shin testing
   • Rapid alternating movements
   • Assess gait when patient is stable enough to ambulate

6. Reflexes

   • Deep tendon reflexes in upper and lower extremities
   • Plantar responses (Babinski sign)
   • Check for clonus

7. Meningeal Signs

   • Nuchal rigidity
   • Kernig's and Brudzinski's signs
   • Particularly important if fever is present

Post-Examination Diagnostic Testing

1. Laboratory Studies

   • Serum glucose and sodium levels for all patients with first-time seizure 1
   • Pregnancy test for women of childbearing age 1
   • Consider toxicology screen if substance use is suspected

2. Neuroimaging

   • Perform brain CT or MRI in the ED for patients with first-time seizure when feasible 1
   • Urgent neuroimaging for patients with:
     • Focal neurological deficits
     • Fever
     • Recent trauma
     • Persistent altered mental status
     • Age >40 years
     • History of malignancy or immunocompromise
     • Anticoagulation therapy
     • Focal onset seizure 1

3. EEG Considerations

   • Perform EEG promptly in patients who don't follow commands after seizure resolution 1
   • Consider continuous or repeated EEG monitoring for patients with altered mental status 1
   • Evaluate for nonconvulsive seizures and ictal-interictal patterns 1

Special Considerations

• Postictal State Assessment: The postictal state begins at seizure termination and continues until return to baseline. This period can be difficult to define precisely, especially with complex partial seizures 2.

• Lumbar Puncture: Perform lumbar puncture (after neuroimaging) in immunocompromised patients or when meningitis/encephalitis is suspected 1.

• Swallowing Assessment: Keep patient NPO until swallowing ability is assessed, especially after seizures associated with stroke 1.

• Recurrent Seizure Risk: Monitor closely for 24 hours as seizure recurrence rates of 9-19% have been reported within the first 24 hours after a first seizure 1.

Common Pitfalls to Avoid

1. Failing to recognize nonconvulsive status epilepticus in patients with persistent altered mental status

2. Missing underlying causes such as metabolic abnormalities, stroke, infection, or toxins

3. Premature diagnosis of epilepsy after a single provoked seizure

4. Inadequate observation period after a first seizure

5. Overlooking subtle focal deficits that may indicate a structural lesion

6. Prophylactic use of anticonvulsants which is not recommended after a single seizure 1

7. Neglecting to document baseline mental status for comparison during recovery

By systematically following this approach, clinicians can effectively evaluate patients after seizures, determine appropriate management, and identify those requiring urgent intervention or admission.