What is the initial evaluation and management for a patient presenting with a seizure?

Initial Evaluation and Management for a Patient Presenting with a Seizure

The initial evaluation for a patient presenting with a seizure should include neuroimaging of the brain in the emergency department, determination of serum glucose and sodium levels, and consideration for admission if abnormal findings are present or the patient has not returned to baseline.1, 2

Initial Assessment

History Taking

• Focus on seizure characteristics: timing, duration, focal vs. generalized onset, loss of consciousness, and post-ictal state 2
• Document any history of head trauma, malignancy, immunocompromised status, fever, persistent headache, anticoagulation use, or focal neurological symptoms 1
• Assess for potential seizure triggers: sleep deprivation, alcohol use, recreational drugs, medication changes 1
• Determine if this is a first-time seizure or recurrent event 2

Physical Examination

• Complete neurological examination to identify focal deficits that may indicate structural brain lesions 2
• Assess vital signs, with particular attention to fever which may suggest infection 2
• Evaluate for signs of head trauma or tongue biting 1
• Document mental status and determine if patient has returned to baseline 3

Diagnostic Workup

Laboratory Testing

• Obtain serum glucose and sodium levels for all patients, as these are the most frequent abnormalities identified in seizure patients 2, 3
• Consider pregnancy test for all women of childbearing age 2, 3
• Additional laboratory tests should be guided by clinical circumstances (e.g., liver function tests, toxicology screen if substance abuse is suspected) 2
• Consider checking urine for blood to detect rhabdomyolysis, which can be a complication of seizures 3

Neuroimaging

• Perform neuroimaging of the brain in the ED for patients with first-time seizures when feasible 1, 3
• Head CT should be performed emergently when an acute intracranial process is suspected, particularly in patients with:
  • History of acute head trauma
  • History of malignancy
  • Immunocompromised status
  • Fever
  • Persistent headache
  • History of anticoagulation
  • New focal neurologic examination
  • Age older than 40 years
  • Focal onset before generalization 1, 3
• MRI is preferred for non-emergent situations 3

Additional Testing

• Consider EEG as part of the neurodiagnostic evaluation, though this may be deferred to outpatient follow-up 2
• Perform lumbar puncture when there is concern for meningitis or encephalitis, or in immunocompromised patients 2

Management

Immediate Management

• Keep patient NPO until swallowing assessment is completed to prevent aspiration 4
• Monitor for changes in neurological status 4
• Consider alternative routes for medication administration while patient is NPO 4

Antiepileptic Drug (AED) Therapy

• Emergency physicians need not start AEDs in patients with a first unprovoked seizure who have returned to their clinical baseline in the ED 2
• If AED therapy is indicated based on risk factors or recurrence, options include:
  • Levetiracetam: Initial dose of 1000 mg/day in two divided doses 5
  • Valproic acid: Initial dose of 10-15 mg/kg/day, increased by 5-10 mg/kg/week as needed 6

Disposition Decisions

Admission Criteria

• Consider admission if any of the following are present:
  • Persistent abnormal neurologic examination
  • Abnormal investigation results
  • Patient has not returned to baseline 2, 3
  • Age ≥40 years, alcoholism, hyperglycemia, or Glasgow Coma Scale score <15 (risk factors for early seizure recurrence) 4

Discharge Criteria

• Patients with a first unprovoked seizure who have returned to their clinical baseline in the ED may not require admission 2, 3
• Ensure reliable follow-up is available for deferred outpatient neuroimaging 1
• Provide seizure precautions and driving restrictions 7

Risk of Recurrence

• Mean time to first seizure recurrence is 121 minutes (median 90 minutes) with more than 85% of early recurrences happening within 6 hours 1, 4, 3
• Non-alcoholic patients with new-onset seizures have the lowest early seizure recurrence rate (9.4%) 2, 3

Common Pitfalls to Avoid

• Failing to identify metabolic abnormalities such as hypoglycemia or hyponatremia that may be causing the seizure 2, 8
• Missing structural lesions by not performing appropriate neuroimaging 2, 3
• Allowing oral intake too early before proper swallowing assessment, which can lead to aspiration pneumonia 4
• Failing to recognize that a patient's swallowing ability can change in the hours following seizures 4