What is the initial management for a patient presenting with seizures?

Initial Management for a Patient Presenting with Seizures

When a patient presents with seizures, perform neuroimaging of the brain in the emergency department, particularly for first-time seizures, to identify potential structural causes requiring urgent intervention. 1

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC):

  • Ensure patent airway
  • Provide supplemental oxygen if needed
  • Establish IV access
  • Monitor vital signs

• Immediate Interventions for Active Seizure:

  • Position patient on their side to prevent aspiration
  • Remove dangerous objects from vicinity
  • Do not force anything into the mouth
  • Time the seizure duration

Diagnostic Evaluation

History (Focused on Seizure Characteristics)

• Timing and duration of seizure
• Presence of aura or warning signs
• Focal features (eye/head deviation, asymmetric movements)
• Post-ictal state (confusion, weakness, headache)
• Precipitating factors (sleep deprivation, alcohol withdrawal, medications)
• History of prior seizures or neurological disorders
• Recent head trauma
• Medication history (including non-compliance with antiepileptic drugs)

Physical Examination

• Complete neurological examination focusing on:
  • Focal deficits
  • Meningeal signs
  • Level of consciousness
  • Evidence of head trauma
  • Signs of systemic illness

Laboratory Studies

• Glucose (bedside and laboratory)
• Complete blood count
• Basic metabolic panel (sodium, calcium, magnesium)
• Liver and kidney function tests
• Toxicology screen if indicated
• Consider lumbar puncture if infectious etiology suspected

Neuroimaging

• CT scan of the head should be performed in the ED for patients with first-time seizures 1
• Urgent neuroimaging is particularly indicated for:
  • Focal neurological deficits
  • Persistent altered mental status
  • History of trauma, malignancy, or immunocompromise
  • Fever or persistent headache
  • Patients on anticoagulation
  • Age >40 years
  • Focal onset before generalization

Management Based on Etiology

Acute Symptomatic Seizures

• Identify and treat the underlying cause:
  • Infections (36.2% of acute symptomatic seizures) 2
  • Stroke (29.8% of acute symptomatic seizures) 2
  • Metabolic disturbances (12.8% of acute symptomatic seizures) 2
  • Toxic causes (10.6% of acute symptomatic seizures) 2

First Unprovoked Seizure

• Patients with a first unprovoked seizure who have returned to their clinical baseline do not necessarily require hospital admission 1
• Consider antiepileptic drug therapy for patients with:
  • High risk of recurrence (history of brain insult, epileptiform abnormalities on EEG, or structural lesion on imaging) 3
  • Remote symptomatic seizures (history of stroke, trauma, tumor, or other CNS disease) 1

Treatment Decisions

Antiepileptic Drug (AED) Initiation

• For first unprovoked seizure: Generally wait for second seizure before starting AEDs unless high risk factors present 1
• For recurrent unprovoked seizures (epilepsy): Start AED therapy 3
• For acute symptomatic seizures: Treat underlying cause; short-term AEDs may be appropriate 4

AED Selection (if indicated)

• For partial seizures: Most AEDs are effective as initial monotherapy 3
• For generalized seizures: Consider valproate, lamotrigine, or topiramate 3
• Valproate dosing (if selected):
  • Initial dose: 10-15 mg/kg/day
  • Increase by 5-10 mg/kg/week to achieve clinical response
  • Optimal response typically at doses below 60 mg/kg/day 5

Disposition

Admission Criteria

• Status epilepticus or recurrent seizures in the ED
• Failure to return to baseline mental status
• Acute symptomatic seizure with uncorrected precipitating factor
• Significant abnormality on neuroimaging
• Inadequate social support for outpatient management

Discharge Criteria

• Return to baseline mental status
• Single self-limited seizure with no recurrence
• Normal or non-acute findings on neuroimaging
• Reliable follow-up available for deferred outpatient neuroimaging 1
• Responsible adult to observe patient

Patient Education and Follow-up

• Seizure precautions and safety measures
• Driving restrictions according to local laws
• Medication instructions if prescribed
• Arrange follow-up with neurology
• Advise on seizure triggers to avoid (sleep deprivation, alcohol)

Common Pitfalls to Avoid

• Failing to distinguish epileptic seizures from non-epileptic events (syncope, psychogenic events)
• Missing treatable causes of acute symptomatic seizures
• Inappropriate use of long-term AEDs for provoked seizures
• Inadequate neuroimaging in high-risk patients
• Overlooking medication non-compliance in patients with known epilepsy