What safety precautions should be taken when sending a patient home after their first seizure?

Safety Counseling for Patients After First Seizure

Patients with a first unprovoked seizure who have returned to their clinical baseline can be safely discharged home without admission, but require specific safety education to prevent injury from potential recurrent seizures. 1

Critical Safety Instructions to Provide

Immediate Seizure Precautions at Home

Patients and caregivers must understand basic seizure first aid to prevent injury and death:

• Position the patient on their side (recovery position) during any future seizure to reduce aspiration risk if vomiting occurs 2
• Clear the surrounding area of hard objects, furniture, or anything that could cause injury during seizure movements 2
• Never restrain the person or put anything in their mouth (fingers, spoons, bite blocks) as this causes dental trauma, airway obstruction, or musculoskeletal injury 2
• Stay with the person throughout the entire seizure episode to monitor for complications 2
• Do not give food, liquids, or oral medications during or immediately after a seizure due to aspiration risk 2

When to Call 911

Educate patients and families to activate emergency services if: 2

• The seizure lasts more than 5 minutes (may not stop spontaneously and requires emergency anticonvulsants)
• Multiple seizures occur without return to baseline mental status between episodes
• The seizure is accompanied by traumatic injury (head injury, significant bleeding, suspected fractures)
• The patient does not return to baseline within 5-10 minutes after the seizure stops
• The seizure occurs in water or is accompanied by choking or difficulty breathing

High-Risk Activities to Avoid

Driving Restrictions

Patients must be explicitly counseled about driving restrictions, which vary by jurisdiction but typically require a seizure-free period before resuming driving. 3 This is a critical safety discussion that should occur at the first seizure encounter.

Environmental Hazards

Specific activity modifications to prevent injury or death: 4

• Avoid swimming alone or in unsupervised settings (seizures in water carry high mortality risk) 2
• Avoid heights including ladders, scaffolding, or working on roofs
• Shower instead of bathing to reduce drowning risk; if bathing, use shallow water and inform someone nearby
• Avoid operating heavy machinery or power tools until cleared by a neurologist
• Use protective measures when cooking (microwave preferred over stovetop, avoid carrying hot liquids)

Seizure Recurrence Risk Education

Approximately one-third to one-half of patients with a first unprovoked seizure will have a recurrent seizure within 5 years. 1 However, the highest risk period is early:

• More than 85% of early recurrent seizures occur within 6 hours of the initial event, with mean time to recurrence of 121 minutes 1
• Patients with CNS injury history (stroke, traumatic brain injury, tumor) have substantially higher recurrence rates and should be counseled accordingly 1

Medication Counseling (If Prescribed)

For patients with first unprovoked seizures, antiepileptic medication is generally not initiated immediately as the strategy of waiting until a second seizure is considered appropriate (NNT = 14 to prevent one recurrence in first 2 years). 1

However, antiepileptic medication should be initiated after a first seizure in patients with: 1

• History of stroke, trauma, tumor, or other CNS disease (remote symptomatic seizure)
• Provoked seizures with identified symptomatic cause (NNT = 5 to prevent recurrence in first year)

Follow-Up Arrangements

Ensure early specialist assessment with neurology, as optimal management strategies require careful history-taking and evaluation for underlying causes. 4, 3

Provide written discharge instructions including all safety precautions, emergency contact numbers, and clear follow-up appointments. 3

Common Pitfalls to Avoid

• Do not minimize the psychological impact: First seizures are perceived as devastating events by patients and families, and the cognitive and emotional impact is often neglected 4
• Do not assume patients know basic seizure first aid: Surveys demonstrate deep unmet needs in seizure first aid education even among caregivers 5
• Do not discharge without explicit driving counseling: This is a medico-legal requirement and critical safety issue 3
• Do not forget to address work restrictions: Patients may need temporary work modifications depending on their occupation 4