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

Initial Workup and Treatment for Seizures

The initial workup for a patient presenting with seizures should include emergent neuroimaging (CT or MRI) for patients with focal neurologic deficit, persistent altered mental status, history of trauma or malignancy, immunocompromised state, fever, persistent headache, age over 40 years, or focal onset seizure, along with essential laboratory tests including serum glucose, sodium, and other tests based on clinical presentation. 1

Initial Assessment and Stabilization

1. Airway, Breathing, Circulation (ABC) Assessment

   • Ensure patent airway and adequate oxygenation
   • Monitor vital signs including heart rate, blood pressure, temperature, and oxygen saturation
   • Establish IV access

2. Immediate Seizure Management

   • For ongoing seizures (>5 minutes) or recurrent seizures without return to baseline:
     • First-line: Benzodiazepines - lorazepam 4 mg IV 1
     • Second-line (if refractory): Phenytoin, fosphenytoin, or valproate IV 1

3. Detailed Seizure Description

   • Document exact seizure duration, initial body part involved, progression of movements
   • Note presence of automatisms or vocalization
   • Assess post-ictal state (duration of confusion, focal deficits, time to return to baseline)

Laboratory Evaluation

Essential laboratory tests based on clinical presentation:

Laboratory Test	Indication
Serum glucose	All patients
Serum sodium	All patients
Pregnancy test	Women of childbearing age
Complete metabolic panel	Altered mental status
Toxicology screen	Altered mental status, suspected substance use
CBC, blood cultures	Fever
Antiepileptic drug levels	Patients on seizure medications
CK levels	Generalized tonic-clonic seizure
Troponin levels	Older patients with generalized tonic-clonic seizure

Neuroimaging

1. Emergent Neuroimaging Indications 1:

   • Focal neurologic deficit
   • Persistent altered mental status
   • History of trauma or malignancy
   • Immunocompromised state
   • Fever
   • Persistent headache
   • Age over 40 years
   • Focal onset seizure

2. Imaging Modality:

   • MRI is preferred when available 1
   • CT may be performed initially in emergency settings, especially when acute intracranial bleeding is suspected

Additional Diagnostic Testing

• EEG: Recommended for all patients with first unprovoked seizure 1
• Lumbar Puncture: Indicated if signs of meningitis/encephalitis are present 1

Treatment Approach

1. Acute Symptomatic Seizures:

   • Identify and treat underlying cause (hypoglycemia, electrolyte abnormalities, infection, drug toxicity)
   • Prophylactic anticonvulsants are not recommended 1

2. First Unprovoked Seizure:

   • Antiepileptic medications should not be initiated unless specific risk factors for recurrence are present:
     • History of previous brain disease/injury
     • Abnormal EEG
     • Abnormal neuroimaging findings
     • Focal onset seizure 1

3. Established Epilepsy (≥2 unprovoked seizures):

   • Initiate appropriate antiepileptic medication based on seizure type:
     • For partial seizures: Valproic acid starting at 10-15 mg/kg/day, increasing by 5-10 mg/kg/week to optimal response (usually <60 mg/kg/day) 2
     • For primary generalized tonic-clonic seizures: Consider topiramate or valproate 3, 2

Disposition Criteria

1. Discharge Criteria 1:

   • 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 1:

   • Status epilepticus or recurrent seizures
   • Persistent altered mental status
   • Acute symptomatic seizure
   • Significant abnormality on neuroimaging requiring urgent intervention
   • Inability to complete outpatient workup

Special Considerations

• Elderly patients: May experience more profound sedation with benzodiazepines 1
• Alcohol withdrawal seizures: Treat with benzodiazepines (phenytoin is ineffective) 1
• Driving restrictions: Counsel patients on local laws regarding driving after a seizure 1

Discharge Instructions

• Seizure precautions and safety measures
• Medication instructions if prescribed
• Follow-up with neurology
• Seizure trigger avoidance (alcohol, sleep deprivation, stress)
• When to seek emergency care

The American College of Emergency Physicians guidelines emphasize that patients with a normal neurologic examination, normal test results, and no structural brain disease do not require hospitalization or antiepileptic medications after a first seizure 1, 4. Treatment decisions should be based on the risk of recurrence and potential impact on quality of life.