What is the most appropriate next step in management for a patient with acute agitation and confusion, who used synthetic cannabinoid (K2) and demonstrated tonic-clonic activity?

Management of K2-Associated Brief Seizure with Return to Baseline

Discharge is the most appropriate next step in management for this patient who experienced a brief, self-limited seizure after synthetic cannabinoid (K2) use and has returned to baseline mental status. 1

Rationale for Discharge

The patient meets criteria for safe discharge based on several key factors:

• The seizure was brief (15 seconds), self-limited, and did not require intervention 1
• Mental status has improved and the patient is now sober, indicating return to baseline 1
• The seizure occurred in the context of a clear provoking factor (synthetic cannabinoid use) 2, 3
• The American Academy of Child and Adolescent Psychiatry recommends emergency services activation only for first-time seizures, seizures lasting >5 minutes, or failure to return to baseline within 5-10 minutes after seizure activity 1

Why Other Options Are Not Indicated

EEG is not routinely indicated in the emergency department for provoked seizures:

• The 2004 ACEP clinical policy on seizure management does not recommend routine ED EEG for patients who have returned to baseline after a provoked seizure 4
• EEG abnormalities associated with synthetic cannabinoid use (bifronto-centrally predominant sharp waves) typically resolve within days without intervention 2
• Admission for EEG monitoring would only be warranted if the patient had persistent altered mental status or recurrent seizures 4

Neurology consultation is not necessary:

• Consultation is reserved for recurrent prolonged seizures or failure to return to baseline 1
• This was a single, brief, provoked seizure with full recovery 3

Prophylactic antiepileptic medication (levetiracetam) is not indicated:

• Synthetic cannabinoid-associated seizures are provoked seizures, not epilepsy 2, 3
• The seizure recurrence rate after synthetic cannabinoid-provoked seizures is similar to other acute systemic insults and does not warrant prophylaxis 3
• Starting antiepileptic drugs is not recommended for single provoked seizures 4

Discharge Instructions and Follow-up

Provide clear counseling on synthetic cannabinoid risks:

• Synthetic cannabinoids have intrinsic proconvulsant effects, with seizures typically occurring within 30 minutes of inhalation 3
• Seizure recurrence occurs primarily with repeated synthetic cannabinoid use 3
• Advise complete avoidance of synthetic cannabinoids 2, 3

Return precautions should include:

• Recurrent seizures 1
• Failure to maintain normal mental status 1
• Any seizure lasting >5 minutes 1

Important Clinical Pitfalls

Do not confuse provoked seizures with epilepsy: The presence of epileptiform discharges on EEG in synthetic cannabinoid users does not necessarily indicate underlying epilepsy, as these abnormalities resolve spontaneously 2. Synthetic cannabinoids themselves may generate epileptiform discharges and lower seizure threshold in otherwise healthy individuals 2.

Recognize the toxidrome: The constellation of acute agitation, confusion, and seizures in the context of synthetic cannabinoid use represents a recognized toxidrome that typically resolves with supportive care and abstinence 2, 5.