What is the disposition for a patient with new onset seizure?

From the Guidelines

For a patient with a new onset seizure, immediate medical attention is required, and the patient should be referred to the emergency department for evaluation, which typically includes neuroimaging, blood tests, and an electroencephalogram (EEG) 1. The evaluation process is crucial in determining the underlying cause of the seizure and guiding further management.

Key Components of Evaluation

• Neuroimaging (CT or MRI) to rule out structural abnormalities
• Blood tests, including complete blood count, electrolytes, glucose, calcium, magnesium, and drug screen, to identify potential precipitating factors
• Electroencephalogram (EEG) to assess for abnormal electrical activity in the brain After initial stabilization, consultation with a neurologist is recommended to determine the need for antiepileptic drug therapy, which is not always initiated after a single unprovoked seizure, as the risk of recurrence varies (30-50% within two years) 1.

Considerations for Antiepileptic Drug Therapy

• Risk factors such as abnormal EEG, structural brain abnormality, or nocturnal seizures may warrant treatment
• First-line medications include levetiracetam, lamotrigine, or carbamazepine, with dosing and titration guided by clinical response and side effect profile Patients should be advised to avoid driving until cleared by their physician (typically 3-6 months seizure-free), avoid alcohol, maintain regular sleep patterns, and take medications consistently 1. Regular follow-up is essential to monitor for medication side effects, seizure control, and adjust treatment as needed.

Follow-up and Ongoing Management

• Follow-up should occur within 2-4 weeks of the initial event
• Regular monitoring for medication side effects and seizure control is crucial to optimize treatment and improve patient outcomes 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Disposition for New Onset Seizure

• The management of new onset seizures is a critical issue in emergency medicine, with studies suggesting that seizure- and epilepsy-related complications account for 5% of 911 calls and 1% of emergency department visits 2.
• Emergency physicians and neurologists must be able to recognize and treat seizure- and epilepsy-related emergencies, including new onset seizures, breakthrough seizures, status epilepticus, and acute adverse effects of antiepileptic drugs 2, 3.
• The evaluation and management of new onset seizures involve a range of factors, including laboratory tests, imaging studies, and the use of antiepileptic drugs 4.
• Studies have shown that immediate antiepileptic drug therapy may reduce the risk of recurrence within the first 2 years, but may not improve quality of life or long-term prognosis 5.
• The decision to initiate immediate antiepileptic drug treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the adverse events of antiepileptic drug therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years 5.

Treatment Options

• Levetiracetam and zonisamide are licensed as monotherapy for focal epilepsy, but studies have shown that they may not be as effective as lamotrigine or valproate in certain cases 6.
• Valproate is a commonly used antiepileptic drug for generalized and unclassifiable epilepsy, but it may have a higher risk of adverse events, particularly in women of childbearing potential 6.
• Phenytoin and fosphenytoin are also used to prevent seizure recurrence, but the optimal dosing strategies are not well established 4.

Diagnostic Evaluation

• Electroencephalographic (EEG) testing may be performed in the emergency department to evaluate patients with new onset seizures, but the timing and indications for EEG testing are not well established 4.
• Imaging studies, such as head computed tomography (CT) scans, may be indicated in certain cases, such as patients with new onset seizures who have returned to a normal baseline but have a history of trauma or other risk factors for intracranial abnormalities 4.