Management of Patients Presenting with Seizures
Patients presenting with seizures require immediate assessment for life-threatening causes, stabilization of airway/breathing/circulation, and treatment of ongoing seizures, followed by a systematic approach to identify and address the underlying cause.
Initial Emergency Management
Immediate Stabilization
- Ensure airway patency and adequate oxygenation
- Establish IV access
- Check blood glucose (all patients)
- Position patient to prevent aspiration
- Protect from injury during active seizure
Active Seizure Management
- For seizures lasting >5 minutes or recurrent seizures without return to baseline (status epilepticus):
Diagnostic Evaluation
Essential Laboratory Tests
- Serum glucose and 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, lumbar puncture (if fever present)
- Antiepileptic drug levels (patients on seizure medications)
- CK levels (after generalized tonic-clonic seizure)
- Troponin levels (older patients with generalized tonic-clonic seizure) 1
Imaging
- MRI of the brain is preferred for new-onset seizures in non-emergent setting 1
- CT head may be performed emergently if:
- Focal neurologic deficits
- History of trauma
- Persistent altered mental status
- Suspected intracranial lesion
Electroencephalography (EEG)
- Recommended as part of neurodiagnostic evaluation to:
- Identify epilepsy syndromes
- Predict recurrence risk
- Consider continuous EEG monitoring if mental status remains altered 1
Treatment Approach Based on Seizure Classification
Provoked Seizures
- Do not initiate antiepileptic medication in the ED for patients with provoked seizures 2
- Identify and treat precipitating medical conditions:
- Organ failure
- Electrolyte imbalance
- Medication effects or withdrawal
- Toxic exposures
- Infection 3
First Unprovoked Seizure
- Emergency physicians need not initiate antiepileptic medication in the ED for patients who have had an unprovoked seizure without evidence of brain disease or injury 2
- For patients with first unprovoked seizure with remote history of brain disease/injury:
- Emergency physicians may initiate antiepileptic medication in the ED, or defer in coordination with other providers 2
- Risk factors for recurrence include:
- Remote neurologic insult
- Epileptiform abnormalities on EEG
- Focal structural lesion on neuroimaging
- Family history of epilepsy 4
Known Seizure Disorder
- Resume appropriate antiepileptic medication
- Check medication compliance and drug levels
- Evaluate for breakthrough seizure triggers
Disposition
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 1
Admission Criteria
- Status epilepticus
- Persistent altered mental status
- Acute symptomatic seizure requiring treatment of underlying cause
- Significant comorbidities
- Inability to follow up or lack of social support
Discharge Instructions
- Seizure precautions and safety measures
- Driving restrictions according to local laws
- Medication instructions if prescribed
- Arrangement for follow-up with neurology
- Advice on seizure triggers to avoid 1
Special Considerations
- Phenytoin is ineffective for seizures secondary to alcohol withdrawal, theophylline, or isoniazid toxicity 3
- Control of blood pressure is important in patients with renal failure and seizures 3
- Consider non-convulsive status epilepticus in any patient with unexplained confusion or coma 3
- Most patients with secondary seizures do not have epilepsy and do not require long-term antiepileptic treatment 3