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

Seizure Workup and Treatment Protocol

The recommended workup for a patient presenting with seizures includes neuroimaging of the brain in the emergency department, basic laboratory tests including glucose and sodium levels, and consideration of antiepileptic drug therapy based on seizure recurrence risk and underlying etiology. 1

Initial Diagnostic Workup

Laboratory Testing

• Essential laboratory tests:

  • Serum glucose and sodium levels 1
  • Pregnancy test for women of childbearing age 1
  • Consider urine dipstick for blood to detect rhabdomyolysis 1

• Conditional laboratory tests:

  • Drug screen if substance abuse is suspected 1
  • Complete metabolic panel for patients with comorbidities, malnutrition, or on diuretics 1
  • Anticonvulsant levels for patients on antiepileptic medications 2

Neuroimaging

• Brain CT scan in the ED is indicated for:

  • First-time seizure 1
  • Patients with focal neurologic deficits 1
  • Persistent altered mental status 1
  • Recent trauma 1
  • Persistent headache 1
  • History of cancer or immunocompromise 1
  • Patients on anticoagulation 1
  • Age >40 years 1
  • Fever (to rule out CNS infection) 1

• MRI is preferred when available as it provides better visualization of structural abnormalities, though it may be deferred to outpatient setting when reliable follow-up is available 1

Additional Testing

• Lumbar puncture:

  • Indicated for immunocompromised patients (after CT scan) 1
  • Indicated when CNS infection is suspected 1

• EEG:

  • Should be performed within 24 hours after a seizure 3
  • If normal during wakefulness, a sleep EEG is recommended 3

Treatment Approach

Acute Management

1. For provoked seizures:

   • Identify and treat the underlying cause (metabolic abnormalities, toxins, etc.) 1, 4
   • Antiepileptic drugs not indicated for isolated provoked seizures 5

2. For first unprovoked seizure:

   • Consider antiepileptic drug therapy if:
     • High risk for recurrence (brain insult history, epileptiform EEG abnormalities, structural lesion on imaging) 5
     • Recurrence would have significant psychosocial impact 5

3. For established epilepsy (≥2 unprovoked seizures):

   • Initiate antiepileptic drug therapy 5

Medication Selection

• For partial seizures:

  • Levetiracetam: Start with 500 mg BID, titrate to maximum 3000 mg/day 6
  • Topiramate: Start with 25 mg BID, titrate to 200-400 mg/day 7
  • Valproic acid: Start with 10-15 mg/kg/day, titrate to optimal response (usually <60 mg/kg/day) 8

• For generalized seizures:

  • Valproic acid: Start with 15 mg/kg/day, titrate up to 60 mg/kg/day 8
  • Levetiracetam: Start with 500 mg BID, titrate to 3000 mg/day 6
  • Topiramate: Start with 25 mg BID, titrate to 400 mg/day 7

Disposition Decisions

Hospital Admission Criteria

• Patients with abnormal neuroimaging showing acute lesions 1
• Patients with status epilepticus or recurrent seizures in the ED 1
• Patients with significant metabolic abnormalities 1
• Patients with suspected CNS infection 1
• Patients with first-time seizure and high risk of recurrence within 24 hours 1

Safe for Discharge

• Return to baseline mental status 1
• Normal neurologic examination 1
• No evidence of acute intracranial process 1
• Reliable follow-up available 1
• Adequate social support 1

Common Pitfalls to Avoid

1. Overreliance on laboratory testing: Clinical examination can accurately predict the need for most laboratory studies. Routine serum chemistries have extremely low yield in patients without clinical indications 2.

2. Failure to identify non-epileptic events: Many conditions mimic seizures, including pseudoseizures, syncope, migraine, and movement disorders. Careful history focusing on event details is essential 5.

3. Inappropriate antiepileptic drug use: Not starting treatment when indicated or prescribing inappropriate medications for seizure type can lead to continued seizures and complications 5.

4. Inadequate follow-up planning: Ensuring timely neurological follow-up is critical, especially for patients with first-time seizures who are discharged from the ED 1.

5. Missing underlying causes: Failure to identify and address treatable causes of seizures (metabolic, toxic, structural) can lead to recurrent events and potential harm 4.

By following this structured approach to seizure workup and treatment, clinicians can effectively diagnose the cause of seizures, initiate appropriate treatment, and ensure proper disposition and follow-up care.