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

Initial Evaluation and Treatment of Seizures

For patients presenting with seizures, the initial evaluation should include comprehensive diagnostic workup with imaging (preferably MRI), EEG within 24-48 hours, and essential laboratory tests including serum glucose, sodium, pregnancy test in women of childbearing age, and other tests based on clinical presentation. 1

Initial Assessment

Immediate Stabilization

1. Ensure airway, breathing, circulation
2. Position patient to prevent aspiration
3. Administer oxygen if needed
4. Establish IV access

Essential Laboratory Tests

• All patients: Serum glucose, serum sodium
• Women of childbearing age: Pregnancy test
• Altered mental status: Complete metabolic panel, toxicology screen
• Fever present: CBC, blood cultures, consider lumbar puncture
• Patients on seizure medications: Antiepileptic drug levels
• After generalized tonic-clonic seizure: CK levels
• Older patients with generalized seizures: Troponin levels 1

Neuroimaging

• MRI is preferred over CT for detecting brain abnormalities 1
• CT scan appropriate when acute intracranial bleeding is suspected or in emergency settings
• Neuroimaging should be avoided in patients with typical febrile seizures or primary generalized epilepsy with characteristic clinical and EEG features 1

Electroencephalography (EEG)

• Should be performed within 24-48 hours of seizure 1
• If normal during wakefulness, a sleep EEG is recommended 2
• Helps differentiate seizure types and identify epilepsy syndromes

Treatment Approach

Active Seizure Management

1. First-line: Benzodiazepines 1
2. Second-line (if seizures persist): Levetiracetam, fosphenytoin, or valproate (all equally effective) 1
3. Medication selection considerations:
   • Levetiracetam: Preferred in patients with hepatic dysfunction 1
   • Valproate: Avoid in patients with potential hepatotoxicity 1
   • Phenytoin: May be ineffective for seizures due to alcohol withdrawal, theophylline or isoniazid toxicity 3

Status Epilepticus Management

For status epilepticus (seizure lasting >5 minutes or recurrent seizures without recovery):

1. First-line: Benzodiazepines at optimal doses
2. Second-line: Valproate (30 mg/kg), levetiracetam, or phenobarbital 4
3. Refractory status: Consider transfer to ICU with continuous EEG monitoring 1

Treatment Considerations

• Prophylactic anticonvulsant use is not recommended 1
• Treatment with antiepileptic medications reduces short-term (1-2 year) risk of recurrent seizures but does not reduce long-term risk 5
• For first unprovoked seizure with normal examination and testing, antiepileptic medications are not required 6

Disposition and Follow-up

Discharge Criteria

Patients can be discharged if they:

• Have returned to baseline mental status
• Had a single self-limited seizure with no recurrence
• Have normal or non-acute findings on neuroimaging
• Have reliable follow-up available
• Have a responsible adult to observe them 1

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

Common Pitfalls to Avoid

• Delayed treatment of status epilepticus
• Inadequate benzodiazepine dosing
• Failure to monitor respiratory status
• Missing non-convulsive status epilepticus
• Overlooking treatable causes of seizures 1
• Failing to identify medical causes of seizures (organ failure, electrolyte imbalance, medication effects) 3

Special Considerations

• For acute symptomatic seizures, treatment of the underlying cause is recommended 2
• Non-convulsive status epilepticus should be considered in any patient with confusion or coma of unclear cause 3
• Most patients with secondary seizures do not have epilepsy and do not require long-term anticonvulsant medication 3

By following this structured approach to seizure evaluation and management, clinicians can ensure appropriate care while avoiding unnecessary testing and treatment.