What is the best approach for a patient with severe symptoms, including recent onset of seizure-like activity?

Management of a Patient with Severe Symptoms Including Recent Onset of Seizure-like Activity

For a patient with severe symptoms including recent onset of seizure-like activity, immediate treatment with appropriate short-acting medications such as intravenous lorazepam is recommended if the seizures are not self-limiting. 1, 2

Initial Management of Acute Seizures

• New-onset seizures in patients with acute symptoms should be treated with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting 1, 2
• Active seizures not resolving within 5 minutes (status epilepticus) require prompt intervention with benzodiazepines as first-line treatment 3
• Second-line treatment for persistent seizures includes fosphenytoin, levetiracetam, or valproic acid, all with similar efficacy of 45-47% for seizure cessation 3
• Patients should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status 1, 2

Diagnostic Approach

• Determine serum glucose and sodium levels, as electrolyte abnormalities (particularly hyponatremia and hypocalcemia) are significant seizure triggers 1, 3
• For women of childbearing age, obtain a pregnancy test 1
• Perform neuroimaging (CT scan) in the ED for patients with first-time seizures when feasible 1
• Consider lumbar puncture (after CT scan) in immunocompromised patients 1
• Consider EEG monitoring in patients at high risk of seizures or with unexplained reduced level of consciousness 1, 2
• Investigate for potential metabolic causes including hyponatremia, hypocalcemia, hypomagnesemia, hyperglycemia, and uremia 3

Classification of Seizures

• Determine whether the seizure is provoked (acute symptomatic) or unprovoked 3, 4
• Provoked seizures occur at the time of or within 7 days of an acute neurologic, systemic, metabolic, or toxic insult 3, 5
• Unprovoked seizures occur without acute precipitating factors and include remote symptomatic seizures (resulting from a CNS or systemic insult that occurred more than 7 days in the past) 3, 4

Treatment Decisions

For Provoked Seizures:

• Identify and treat the underlying cause rather than initiating long-term antiseizure medications 1, 3, 5
• Correct any underlying metabolic abnormalities, with temporary seizure control using short-acting antiepileptic medications if necessary 3, 5

For Unprovoked Seizures:

• A single, self-limiting seizure occurring at the onset or within 24 hours after an ischemic stroke should not be treated with long-term anticonvulsant medications 1, 2
• For patients with a first unprovoked seizure without evidence of brain disease or injury who have returned to baseline, antiepileptic medication need not be initiated in the ED 1
• For patients who experienced a first unprovoked seizure with a remote history of brain disease or injury, emergency physicians may initiate antiepileptic medication in the ED or defer in coordination with other providers 1
• For patients with 2 or more recurrent unprovoked seizures, antiepileptic drug therapy is the standard treatment 1, 4

Admission Criteria

• Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED 1
• Consider admission for patients with:
  • Abnormal neurologic examination results 1
  • Abnormal investigation results 1
  • High risk of early seizure recurrence (age >40 years, alcoholism, hyperglycemia, and GCS score <15) 1
  • Inability to ensure adequate follow-up 1

Important Precautions

• Prophylactic use of anticonvulsant medications in patients with ischemic stroke who have not had seizures is not recommended 1, 2
• Evidence suggests that prophylactic AED therapy may be associated with poorer outcomes and negative effects on neurological recovery 2
• Many traditional seizure medications may dampen neural plasticity mechanisms that contribute to behavioral recovery after stroke 2
• The risk of seizure recurrence is higher in patients with a history of CNS injury (inclusive of stroke and traumatic brain injury) 1
• For patients with a first unprovoked generalized seizure, it would be necessary to treat 14 patients to prevent a single seizure recurrence within the first 2 years 1

Follow-up Recommendations

• Arrange outpatient follow-up for patients discharged from the ED 1
• Deferred outpatient neuroimaging may be used when reliable follow-up is available 1
• Explain to patients and their families that most patients with secondary seizures do not have epilepsy and do not require long-term treatment 5
• Only those patients with recurrent seizures and uncorrectable predisposing factors need long-term treatment with anticonvulsant medication 5