What is the appropriate management for a patient who experienced seizure-like activity, presented with a blank stare and pale appearance prior to the seizure, and now complains of headache, feeling tired and cold, but is alert and oriented (A&O) x4?

Management of a Patient with Seizure-Like Activity

The patient who experienced seizure-like activity with pre-ictal blank stare and pallor, followed by post-ictal headache, fatigue, and cold sensation, should receive immediate neuroimaging (preferably head CT) in the emergency department, along with basic laboratory testing including glucose, electrolytes, and toxicology screening if indicated by history. 1, 2

Initial Assessment and Stabilization

• The patient has already been appropriately positioned on their side during the seizure, which is the correct first aid approach to prevent aspiration, especially given the reported vomiting of bile 1
• The patient's return to normal mental status (A&O x4) after the seizure is a positive prognostic sign, though the post-ictal headache, fatigue, and cold sensation are common post-ictal symptoms 3
• The seizure duration (approximately 2 minutes, followed by cessation, then resumption for 30 seconds) is important to document as it helps determine the severity of the seizure 3

Diagnostic Workup

• Perform neuroimaging of the brain (preferably head CT) in the emergency department, as this is recommended for all patients with a first-time seizure 1
• Order the following laboratory tests:
  • Serum glucose and sodium (most common metabolic abnormalities associated with seizures) 2, 4
  • Complete blood count to evaluate for infection or other hematologic abnormalities 2
  • Basic metabolic panel including BUN, creatinine, and electrolytes 2
  • Calcium and magnesium levels 2
  • Toxicology screening if substance use is suspected based on history 2, 4

Differential Diagnosis Considerations

• The blank stare and pallor prior to the seizure may represent the aura phase of a seizure, but could also indicate syncope with seizure-like activity 1
• Tilt-table testing may be reasonable to distinguish convulsive syncope from epilepsy if the diagnosis remains unclear after initial evaluation 1
• Brief seizure-like activity (body stiffening and shaking) can occur during syncope and should not be automatically regarded as indicating epilepsy 1

Treatment Decisions

• For a first-time unprovoked seizure without evidence of brain disease or injury, antiepileptic medication need not be initiated in the emergency department 1
• If there is a history of brain disease or injury, the emergency physician may initiate antiepileptic medication or defer this decision in coordination with other providers 1
• If the seizure was provoked by an identifiable medical condition, treat the underlying condition rather than starting antiepileptic medication 1

Disposition

• If the patient has returned to their clinical baseline in the ED, has a normal neurological examination, and neuroimaging shows no acute abnormalities, they need not be admitted for a first unprovoked seizure 1
• Ensure reliable follow-up is available if outpatient neuroimaging is deferred 1
• Patients with risk factors for early seizure recurrence (age ≥40 years, alcoholism, hyperglycemia, and GCS score <15) should be monitored more closely 1

Patient Education

• Explain to the patient that most individuals with a first-time seizure who return to baseline do not have epilepsy 5
• Advise about common seizure-inducing factors to avoid: sleep deprivation, excessive alcohol consumption, stress, dehydration, and certain medications 6
• Discuss driving restrictions according to local regulations 3
• Provide seizure first aid education to the patient and family 3

Follow-up Recommendations

• Arrange follow-up with a neurologist, ideally within 2 weeks 1
• Consider EEG testing as an outpatient to help determine seizure risk 7
• If the patient has returned to baseline with normal neuroimaging, outpatient follow-up is appropriate rather than hospital admission 1