What is the management plan for a patient experiencing a seizure-like episode, with or without a known history of epilepsy or seizure disorder?

Management of Seizure-Like Episodes

For patients presenting with a seizure-like episode, the immediate priority is to distinguish true seizures from seizure mimics, stabilize the patient, identify provoked versus unprovoked etiology, and determine whether antiepileptic therapy and hospital admission are indicated based on seizure classification and recurrence risk. 1

Initial Assessment and Stabilization

Confirm True Seizure vs. Mimics

• Many conditions mimic seizures including syncope with brief stiffening/jerks, concussion, rigors, and psychogenic nonepileptic seizures—thorough history is essential to distinguish these from true generalized convulsive seizures. 1
• True generalized convulsive seizures involve generalized movements with unresponsiveness reflecting excessive synchronous cortical electrical activity. 1

Immediate Life Support (If Actively Seizing)

• Equipment to maintain patent airway must be immediately available before any intervention. 2
• Monitor vital signs, establish IV access, ensure unobstructed airway, and have artificial ventilation equipment ready. 2
• For active status epilepticus: administer lorazepam 4 mg IV slowly (2 mg/min) for patients ≥18 years; if seizures continue after 10-15 minutes, give additional 4 mg IV dose. 2
• The most important risk with benzodiazepines is respiratory depression—airway patency must be assured and respiration monitored closely. 2

Identify Correctable Acute Causes

• Immediately check and correct hypoglycemia, hyponatremia, and other electrolyte abnormalities (hypocalcemia, hypomagnesemia), as these are significant seizure triggers. 3, 2
• Assess for other metabolic or toxic derangements within 7 days that would classify this as a provoked seizure. 1, 2

Classification: Provoked vs. Unprovoked Seizures

Provoked (Acute Symptomatic) Seizures

• Seizures occurring at time of or within 7 days of acute neurologic, systemic, metabolic, or toxic insult (hyponatremia, withdrawal, toxic ingestions, encephalitis, CNS mass lesions, intracranial hemorrhage). 1, 3
• Examples include subdural hematomas and other structural brain lesions causing seizures in the acute setting. 3

Unprovoked Seizures

• Seizures without acute precipitating factors, including remote symptomatic seizures from CNS/systemic insult >7 days past (prior stroke, traumatic brain injury, cerebral palsy). 1
• Idiopathic seizures and epilepsy (if recurrent) fall into this category. 1

Decision to Initiate Antiepileptic Therapy

First Unprovoked Seizure WITHOUT Brain Disease/Injury

• Do not routinely initiate antiepileptic drugs in the emergency department for patients with first unprovoked seizure who have returned to baseline, normal MRI/EEG, and no history of brain disease. 4
• The WHO explicitly recommends against routine prescription of antiepileptic drugs after first unprovoked seizure. 4
• Approximately one-third to one-half will have recurrence within 5 years, but early treatment only prolongs time to next event without changing 5-year outcomes. 1, 4
• The number needed to treat to prevent one seizure recurrence in first 2 years is 14 patients. 1, 4
• The strategy of waiting until a second seizure before initiating medication is considered appropriate. 1

First Unprovoked Seizure WITH Remote Brain Disease/Injury

• Emergency physicians may initiate antiepileptic medication for patients with first unprovoked seizure who have remote history of brain disease or injury (stroke, traumatic brain injury, cerebral palsy, structural lesions on imaging). 3, 5
• History of CNS injury increases seizure recurrence risk substantially, and treatment is considered appropriate after one seizure. 1
• For provoked seizures and unprovoked seizures with brain disease, the number needed to treat to prevent one additional seizure in the first year is approximately 5. 1

Recurrent Unprovoked Seizures (≥2 Seizures)

• Patients with 2-3 recurrent unprovoked seizures have substantially increased recurrence risk (approximately three-quarters within 5 years) and should receive antiepileptic therapy. 1, 3
• Levetiracetam is recommended as first-line monotherapy (initial dose 500 mg twice daily). 5
• Avoid valproate in women of childbearing potential. 4, 5

Known Seizure Disorder (Epilepsy)

• Resume maintenance antiepileptic medication in the emergency department. 1
• Route of administration (oral vs. IV) should be determined by clinical urgency and patient ability to take oral medications. 1

Decision for Hospital Admission

First Unprovoked Seizure, Baseline Mental Status Restored

• Emergency physicians need not admit patients with first unprovoked seizure who have returned to clinical baseline in the ED. 1
• However, patients with underlying brain disorders (cerebral palsy, structural lesions) should be admitted for observation for at least 6 hours, preferably 24 hours. 5
• More than 85% of early seizure recurrences occur within 6 hours (mean time 121 minutes), so observation during this highest-risk period is critical. 1, 4

Provoked Seizures

• Admission decisions depend on the underlying acute cause and whether it has been corrected. 1
• Alcoholic patients with history of seizures have highest early recurrence rates and warrant closer observation. 1

Recurrent Seizures or Incomplete Recovery

• Admit patients who have not returned to baseline or have recurrent seizures in the ED. 1
• Patients with recurrent generalized seizures and documented structural lesions require aggressive antiepileptic management. 3

Common Pitfalls to Avoid

• Do not default to immediate antiepileptic treatment for first unprovoked seizure without brain disease—observation and neurology follow-up is the appropriate approach. 4
• Do not discharge patients with underlying brain disorders (cerebral palsy, structural lesions) immediately after first seizure—they require observation. 5
• Do not forget to check glucose and electrolytes immediately, as these correctable causes must be identified and treated. 3, 2
• Do not administer benzodiazepines without airway equipment immediately available—respiratory depression is the most important risk. 2
• For patients receiving lorazepam, be alert to prolonged sedation adding to post-ictal impairment of consciousness, especially with multiple doses. 2
• Patients over 50 years may have more profound and prolonged sedation with IV lorazepam. 2

Disposition and Follow-Up

• Arrange urgent neurology follow-up within 1-2 weeks for all patients with first seizure. 5
• Patients who received injectable lorazepam should not operate machinery, drive, or engage in hazardous activities for 24-48 hours or until drowsiness subsides, whichever is longer. 2
• Obtain brain MRI to characterize structural abnormalities and EEG to assess for epileptiform activity in outpatient setting. 5, 6
• If patient fails to respond to initial benzodiazepine therapy, consult neurology and consider additional interventions including concomitant IV phenytoin. 2