Management of Convulsions in Male Patients: First vs. Subsequent Episodes
Treatment differs significantly between first and subsequent seizure episodes, with the key distinction being whether to initiate antiepileptic therapy in the emergency department.
Initial Stabilization (Same for All Episodes)
For any patient presenting with active seizures:
- Administer benzodiazepines immediately for any seizure lasting >5 minutes 1
- Check serum glucose and sodium immediately, as these are the only laboratory abnormalities that consistently alter acute management 1
- Assess whether the patient has returned to neurological baseline, as this determines aggressiveness of workup and need for admission 1
- Midazolam 0.2 mg/kg IM (maximum 6 mg per dose) may be repeated every 10-15 minutes if seizures persist 1
First Episode Management
Distinguish Provoked vs. Unprovoked Seizures
Provoked seizures occur within 7 days of an acute insult (hyponatremia, withdrawal, toxic ingestions, encephalitis, CNS mass lesions, intracranial hemorrhage) 2, 3
Unprovoked seizures have no acute precipitating factors, including remote symptomatic seizures from events >7 days past (prior stroke, traumatic brain injury) 2, 3
Antiepileptic Drug Initiation Decision
For first unprovoked seizures in patients who have returned to baseline: DO NOT routinely initiate antiepileptic drugs in the ED 2
- Early treatment only prolongs time to next event without changing 5-year outcomes 2
- Number needed to treat to prevent one seizure recurrence in first 2 years is 14 patients 2
- Waiting until a second seizure before initiating medication is the appropriate strategy 2
Exception: Consider initiating antiepileptic medication if the patient has:
- Remote history of brain disease or injury (stroke, traumatic brain injury, cerebral palsy) 2
- Abnormal EEG with epileptiform abnormalities 3
For provoked seizures:
- Treat the underlying cause (correct electrolytes, manage withdrawal, treat infection) 3
- Do not routinely load with antiepileptic drugs unless the provoking cause cannot be immediately corrected 3
Hospital Admission Decision for First Episode
Patients with first unprovoked seizure who have returned to clinical baseline do NOT require hospital admission 2
However, admit if any of the following are present:
- Abnormal neurological examination or failure to return to baseline 4, 2
- Underlying brain disorders (observe for at least 6 hours, preferably 24 hours, as 85% of early recurrences occur within 6 hours) 2, 4
- Age ≥40 years, alcoholism, hyperglycemia, or Glasgow Coma Scale score <15 4
- Evidence of acute intracranial process on neuroimaging 4
- Status epilepticus or multiple seizures without return to baseline 4
- Inability to maintain oral intake 4
Neuroimaging for First Episode
Perform head CT emergently if any high-risk features:
- Recent head trauma 1
- Persistent altered mental status beyond expected post-ictal period 1
- New focal neurological deficits 1
- Fever suggesting CNS infection 1
- History of cancer or immunocompromised state 1
- Anticoagulation use 1
- Age >40 years 4
Second/Subsequent Episode Management (Known Seizure Disorder)
Antiepileptic Drug Management
Patients with 2-3 recurrent unprovoked seizures have substantially increased recurrence risk and SHOULD receive antiepileptic therapy 2
For patients already on antiepileptic drugs who present with breakthrough seizure:
Intravenous loading options (if patient cannot take oral medications):
- Fosphenytoin 18 PE/kg IV at maximum rate of 150 PE/min 1
- Valproate up to 30 mg/kg IV at max rate of 10 mg/kg/min 1
- Levetiracetam 1,500 mg IV load 1
Oral loading options (if patient has returned to baseline):
- Phenytoin 20 mg/kg divided in maximum doses of 400 mg every 2 hours 1
- Levetiracetam 1,500 mg oral load 1
Check antiepileptic drug levels if patient is on phenytoin, valproate, carbamazepine, or phenobarbital to assess for subtherapeutic levels 1
Hospital Admission Decision for Subsequent Episodes
The 24-hour recurrence rate in patients with known epilepsy is 9.4% 1
Admit if:
- Persistent abnormal neurological examination 1
- Failure to return to baseline within several hours 1
- Status epilepticus requiring ongoing treatment 1
- Concern for underlying acute process 1
May discharge if:
- Patient has returned to clinical baseline 1
- Normal neurological examination 1
- No persistent altered mental status 1
- No abnormal investigation results requiring inpatient management 1
- Reliable neurology follow-up arrangements established 1
Keep patient under observation for at least 6 hours, as 85% of early seizure recurrences occur within this timeframe 1, 4
Refractory Status Epilepticus (Any Episode)
If seizures persist despite optimal benzodiazepine dosing:
Level A recommendation: Emergency physicians MUST administer an additional antiepileptic medication 3
Level B recommendation (choose one):
- Intravenous phenytoin 3
- Fosphenytoin 3
- Valproate (superior efficacy: 79% seizure control vs. 25% with phenytoin as second-line agent, with fewer adverse effects including no hypotension) 3
Level C recommendation (if above fail):
Simultaneously search for treatable causes: hypoglycemia, hyponatremia, hypoxia, drug toxicity, systemic or CNS infection, ischemic stroke, intracerebral hemorrhage, withdrawal syndromes 3
Critical Pitfalls to Avoid
- Do not routinely start antiepileptic drugs after a first unprovoked seizure in patients who have returned to baseline - this is overtreatment that does not improve long-term outcomes 2
- Do not discharge patients with first seizures without ensuring at least 6 hours of observation - most early recurrences occur in this window 2, 4
- Do not forget to check glucose and sodium - these are the only labs that consistently change acute management 1
- Do not delay benzodiazepines for seizures lasting >5 minutes - early treatment is critical 1
- For refractory status epilepticus, valproate may be superior to phenytoin with better efficacy and safety profile 3