Seizure Workup and Management
The recommended workup for patients presenting with seizures includes serum glucose and sodium testing, pregnancy testing for women of childbearing age, head CT scan for patients with risk factors, and EEG within 24 hours of the seizure, with treatment decisions based on risk of recurrence. 1, 2
Initial Assessment and Stabilization
- Immediately assess airway, breathing, and circulation
- Check vital signs including heart rate, blood pressure, temperature, and oxygen saturation
- Perform neurological examination to identify focal deficits and determine seizure severity
- Administer short-acting benzodiazepines (e.g., lorazepam IV) if seizures are ongoing 2
Laboratory Workup
Essential Tests for First-Time Seizures
- Serum glucose and sodium (Level B recommendation) 1
- Pregnancy test for women of childbearing age (Level B recommendation) 1
Additional Tests Based on Clinical Presentation
- Complete blood count, electrolytes, renal function, and coagulation studies if clinically indicated 2
- Drug screen if substance abuse is suspected, though routine use is not supported by evidence 1
- Lumbar puncture only if:
- Fever is present
- Immunocompromised patient
- Clinical suspicion of CNS infection 1
Neuroimaging
Head CT Scan in Emergency Department
- Recommended for patients with first-time seizures who have: 1, 2
- Focal neurological deficits
- Persistent altered mental status
- History of trauma
- Malignancy or immunocompromise
- Fever or persistent headache
- Anticoagulation therapy
- Age >40 years
- Focal onset before generalization
MRI
- Preferred over CT for detailed evaluation but not necessary in the emergency setting 1
- Should be performed electively in most patients with first-time unprovoked seizures 1, 3
- Not required for patients with confirmed idiopathic generalized epilepsy 3
Electroencephalography (EEG)
- Obtain EEG within 24 hours of seizure for optimal diagnostic yield (51% vs 34% when performed later) 3
- If initial EEG is normal, perform sleep-deprived EEG 4, 3
- EEG helps classify the epilepsy syndrome in 77% of patients 3
Treatment Approach
Acute Management
- Treat underlying cause for acute symptomatic seizures 4
- Do not initiate long-term antiepileptic drugs after a single unprovoked seizure unless specific risk factors for recurrence exist 2
Risk Factors for Recurrence
- Remote history of brain disease or injury (stroke, trauma, tumor, CNS infection)
- Abnormal EEG (especially epileptiform abnormalities)
- Abnormal neuroimaging findings 2
Antiepileptic Drug Selection
For patients requiring treatment:
Partial (focal) seizures:
Generalized seizures:
Disposition Criteria
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
- Responsible adult to observe the patient 2
Admission Criteria
- Status epilepticus or recurrent seizures
- Persistent altered mental status
- Acute symptomatic seizure (e.g., stroke, infection, metabolic derangement)
- Significant abnormality on neuroimaging requiring urgent intervention
- Inability to complete outpatient workup 1, 2
Common Pitfalls and Caveats
- Not all seizure-like events are epileptic seizures; consider pseudoseizures, syncope, migraine, movement disorders 8
- Elevated prolactin levels 10-20 minutes after the event help differentiate epileptic from psychogenic non-epileptic seizures 4
- Phenytoin is ineffective for seizures secondary to alcohol withdrawal, theophylline, or isoniazid toxicity 9
- Consider non-convulsive status epilepticus in any patient with unexplained confusion or altered mental status 9
- Most patients with a single unprovoked seizure do not require long-term antiepileptic medication 2
- Prophylactic use of antiepileptic drugs in stroke patients is not recommended and may negatively affect neurological recovery 2