What is the best course of action for a patient with a history of seizure disorders, such as epilepsy, experiencing new onset shaking after seizures?

New Onset Shaking After Seizures

For a patient with known seizure disorder experiencing new onset shaking after seizures, immediately assess whether this represents ongoing seizure activity (status epilepticus), postictal phenomena, or a new complication requiring urgent intervention. 1

Immediate Assessment and Stabilization

Time the duration of the shaking episode. If shaking continues beyond 5 minutes or multiple episodes occur without return to baseline mental status, this represents status epilepticus requiring immediate benzodiazepine administration. 2, 1 The mean time to seizure recurrence is 121 minutes (median 90 minutes), with 85% of early recurrences occurring within 6 hours. 3, 4

Critical Actions During Active Shaking

• Maintain NPO status until swallowing ability is formally assessed to prevent aspiration, as clinical status can change in the first hours following seizures. 1
• Position the patient on their side in the recovery position to reduce aspiration risk if vomiting occurs during the postictal period. 2
• Clear the area around the patient and help them to the ground if not already supine to minimize injury risk. 2
• Stay with the patient and do not restrain them or place anything in their mouth. 2

Determine if This is Status Epilepticus

Administer benzodiazepines immediately if:

• Shaking/seizure activity lasts >5 minutes 2, 1
• Multiple seizures occur without return to baseline between episodes 2, 1
• Patient has impaired consciousness with confirmed or suspected ongoing electrographic seizures 1

For persistent seizures after benzodiazepines, administer second-line therapy with phenytoin, fosphenytoin, valproate, or levetiracetam. 1 For refractory status epilepticus, consider levetiracetam, propofol, or barbiturates. 1

Diagnostic Evaluation for New Onset Shaking

Laboratory Testing - Selective Approach

Check serum glucose and sodium levels immediately, as these are the only laboratory abnormalities that consistently alter acute management. 3, 4 Hypoglycemia and hyponatremia require immediate intervention. 3

Obtain antiepileptic drug (AED) levels if the patient is on phenytoin, valproate, carbamazepine, or phenobarbital to assess for subtherapeutic levels as a potential cause of breakthrough seizures. 4

Consider pregnancy testing in women of childbearing age, as this significantly impacts medication choices. 4

Neuroimaging Decision Algorithm

Perform emergent head CT without contrast if any high-risk features are present: 3, 4

• Recent head trauma
• Persistent altered mental status beyond several hours
• New focal neurological deficits
• Fever suggesting CNS infection
• History of cancer or immunocompromised state
• Anticoagulation use
• Age >40 years with new partial-onset seizure pattern

For low-risk patients (young, returned to baseline, normal neurologic exam, reliable follow-up), deferred outpatient MRI is acceptable. 3 However, MRI is the preferred imaging modality for non-emergent evaluation as it is more sensitive than CT for detecting epileptogenic lesions. 2, 3

Electroencephalography (EEG)

Consider EEG for patients with: 1, 3

• Unexplained altered mental status persisting after the shaking episode
• Suspected non-convulsive status epilepticus
• Fluctuating level of consciousness
• Need to differentiate between ongoing seizure activity and postictal phenomena

Abnormal EEG findings predict increased risk of seizure recurrence. 3

Disposition Decisions

Patients can be discharged if ALL of the following criteria are met: 4

• Returned to clinical baseline neurological status
• Normal neurological examination
• No persistent altered mental status
• No abnormal investigation results requiring inpatient management
• Reliable follow-up arrangements established

Consider admission for: 3, 4

• Persistent abnormal neurological examination
• Failure to return to baseline within several hours
• Abnormal investigation results requiring inpatient management
• Status epilepticus requiring ongoing treatment
• Concern for underlying acute process (CNS infection, hemorrhage, stroke)

Risk Stratification

The overall 24-hour recurrence rate is 19% in all seizure patients, decreasing to 9% when alcohol-related events and focal CT lesions are excluded. 3 Non-alcoholic patients with known epilepsy have a lower early recurrence rate of 9.4%. 4

Factors associated with higher early seizure recurrence include: 2

• Age ≥40 years
• Alcoholism
• Hyperglycemia
• Glasgow Coma Scale score <15

Common Pitfalls to Avoid

Do not assume all shaking represents seizure activity. Approximately 28-48% of suspected seizures have alternative diagnoses including syncope, nonepileptic seizures, and panic attacks. 3 Careful history is essential to differentiate true seizure activity from other causes of shaking.

Do not allow oral intake before proper swallowing assessment, as aspiration risk remains elevated in the immediate postictal period. 1

Do not miss status epilepticus by failing to recognize that seizures lasting >5 minutes require immediate intervention. 2, 1

For alcohol withdrawal seizures, do not accept this as a diagnosis of exclusion without searching for symptomatic causes, especially in first-time presentations. 3