How do you manage seizures in a patient?

Management of Seizures in Adult Patients

Initial Stabilization and Classification

The first critical step is to distinguish true generalized convulsive seizures from seizure mimics (syncope with jerking, concussion, rigors, psychogenic episodes), then classify the seizure as either provoked or unprovoked, as this classification drives all subsequent management decisions. 1

Provoked vs. Unprovoked Seizures

• Provoked seizures occur at the time of or within 7 days of an acute insult including hyponatremia, other electrolyte abnormalities, alcohol/drug withdrawal, toxic ingestions, encephalitis, CNS mass lesions, or intracranial hemorrhage 2, 1
• Unprovoked seizures occur without acute precipitating factors, including idiopathic seizures and remote symptomatic seizures from CNS injury >7 days prior (stroke, traumatic brain injury, cerebral palsy) 2, 1

Decision to Initiate Antiepileptic Therapy

For Provoked Seizures

Emergency physicians need not initiate antiepileptic medication in the ED for patients with provoked seizures—instead, identify and treat the precipitating medical condition. 2

• Phenytoin is ineffective for seizures secondary to alcohol withdrawal, theophylline toxicity, or isoniazid toxicity 3
• Most patients with provoked seizures do not have epilepsy and this should be explained to patients and families 3

For First Unprovoked Seizure Without Brain Disease

The World Health Organization explicitly recommends against routine prescription of antiepileptic drugs after a first unprovoked seizure, and emergency physicians need not initiate antiepileptic medication in the ED for these patients. 2, 1, 4

• Approximately one-third to one-half of patients will have recurrence within 5 years, but early treatment only prolongs time to the next event without changing 5-year outcomes 2, 4
• The number needed to treat to prevent one seizure recurrence in the first 2 years is 14 patients 2, 4
• The strategy of waiting until a second seizure before initiating medication is considered appropriate 2

For First Unprovoked Seizure With Remote Brain Disease/Injury

Emergency physicians may initiate antiepileptic medication in the ED, or defer in coordination with neurology, for patients with a first unprovoked seizure and remote history of brain disease or injury (stroke, traumatic brain injury). 2, 1

• History of CNS injury increases the possibility of further seizures and provides anatomic substrate for recurrent seizures 2
• The number needed to treat to prevent a single seizure in the first year is approximately 5 for these patients 2

For Recurrent Unprovoked Seizures (2-3 Episodes)

Patients with 2-3 recurrent unprovoked seizures have substantially increased recurrence risk (approximately 75% within 5 years) and should receive antiepileptic therapy. 2, 1

• Levetiracetam is recommended as first-line monotherapy 1
• For partial onset seizures, initiate at 1000 mg/day (500 mg BID), with potential increases by 1000 mg/day every 2 weeks to maximum 3000 mg/day 5
• For primary generalized tonic-clonic seizures, initiate at 1000 mg/day (500 mg BID), increase by 1000 mg/day every 2 weeks to recommended 3000 mg/day 5
• Avoid valproate in women of childbearing potential 4

Decision for Hospital Admission

For First Unprovoked Seizure

Patients with a first unprovoked seizure who have returned to their clinical baseline in the ED do not require hospital admission. 2

• However, patients with underlying brain disorders should be admitted for observation for at least 6 hours, preferably 24 hours 1
• More than 85% of early seizure recurrences occur within 6 hours (mean time 121 minutes), making this the highest-risk period 2, 1, 4

Risk Factors for Early Recurrence

• Age ≥40 years, alcoholism, hyperglycemia, and Glasgow Coma Scale score <15 are associated with early seizure recurrence 2, 4
• Nonalcoholic patients with new-onset seizures have the lowest early recurrence rate (9.4%), while alcoholic patients with seizure history have the highest (25.2%) 2

For Provoked Seizures

Admission decisions depend on whether the underlying acute cause has been corrected. 1

• Control of blood pressure is particularly important in patients with renal failure and seizures 3
• Patients with recurrent seizures or incomplete recovery should be admitted 1

Disposition and Follow-Up

All patients with a first seizure require urgent neurology follow-up within 1-2 weeks, with outpatient brain MRI and EEG to characterize structural abnormalities and assess for epileptiform activity. 1

Critical Pitfalls to Avoid

• Do not routinely prescribe antiepileptic drugs for first unprovoked seizures—the default should be observation and neurology follow-up 1, 4
• Do not use phenytoin for alcohol withdrawal seizures or certain toxic ingestions 3
• Do not discharge patients with provoked seizures until the underlying cause is corrected 2, 1
• Do not forget to explain that most patients with provoked seizures do not have epilepsy 3
• Antiepileptic drugs should be withdrawn gradually to minimize increased seizure frequency 5