II. History: Present Ilness

  1. Interview patient and witnesses for their recollections of event
  2. Careful review of events leading up to Seizure
    1. Provoked (e.g. Alcohol Withdrawal, Head Trauma, drug-induced Seizure) or unprovoked Seizure?
  3. Number of Seizures in the prior 24 hours
  4. Presence of prodromes or auras
    1. Deja Vu Sensation
    2. Mood Changes
    3. Hallucinations
  5. Description of Seizure by reliable witness including focal aspects
    1. Unilateral movements
    2. Eye Deviation
    3. Head turning
    4. Twisting
    5. Limb Jerking
  6. Duration
    1. Time from onset to cessation of motor activity
  7. Postictal duration and observations
    1. Post-Ictal Confusion
    2. Amnesia
  8. Associated Findings
    1. Tongue Biting
    2. Urinary Incontinence
  9. Findings suggesting alternative diagnosis
    1. Chest Pain
    2. Nausea
    3. Dyspnea
    4. Palpitations
    5. Presyncopal symptoms (e.g. light headedness, Dizziness or tunnel Vision)
  10. Provoked Seizure Causes
    1. See Seizure Causes (includes Drug Induced Seizure and Seizure Differential Diagnosis)
    2. Medications (e.g. Bupropion, Diphenhydramine, Tramadol)
    3. Drug Withdrawal (e.g. Alcohol Withdrawal) or Drug Intoxication (e.g. Cocaine)

III. History: Other

  1. Past Medical History
    1. Febrile Convulsions
    2. Head Injury
    3. Vascular disease
      1. Cerebrovascular Accidents
      2. Coronary Artery Disease
    4. Cancer
    5. Infectious disease
    6. Sleep Disorder
    7. Medications (including over the counter, and Herbals)
  2. Family History
    1. Febrile Convulsions
    2. Epilepsy in siblings, parents, or close relatives
    3. History of neurogenic disorders
  3. Social History
    1. Travel
    2. Occupation
    3. Substance Abuse

IV. Exam

  1. Vital Signs including Temperature
  2. Injury pattern
    1. Oral Lacerations (especially lateral Tongue bites)
    2. Urinary Incontinence
    3. Burn injuries are common
  3. Cardiovascular exam
  4. Skin exam
  5. Complete Neurologic Exam
    1. Focal postictal deficits
    2. Focal neurologic deficits after recovery (Todd Paralysis versus Cerebrovascular Accident)
    3. Neuropsychological evaluation

V. Labs: First-line indicated in most patients

  1. Fingerstick Glucose (all patients)
  2. Serum Sodium
  3. Urine Pregnancy Test (in women of child-bearing age)

VI. Labs: As indicated by presentation (e.g. Dehydration, toxic ingestion)

  1. Complete Blood Count
  2. Serum Electrolytes (especially Serum Sodium), Calcium, Magnesium, and Phosphorus
    1. Indicated for gastrointestinal losses, poor oral intake or other suspected cause
    2. Especially consider in infants with new onset Seizure
  3. Serum Glucose
    1. At minimum, check a fingerstick Glucose as above
  4. Renal Function tests
    1. Creatinine
    2. Blood Urea Nitrogen
  5. Liver Function Tests
  6. Erythrocyte Sedimentation Rate (ESR)
  7. Ammonia level (in Cirrhosis history)
  8. Urine Toxicology Screening
  9. Serum drug levels (as indicated)
  10. Serum Prolactin is not typically helpful
    1. Increased in 40-60% within 20 minutes of Seizure (but not increased in 15 to 20% of patients)
    2. However, increased in 25% of non-epileptic Seizures
    3. Serum Prolactin is also increased in Vasovagal Syncope
    4. Abukar (2016) Neurol Clin Pract 6(2): 116-9 [PubMed]
    5. Lusic (1999) Seizure 8(4): 218-22 [PubMed]

VII. Diagnostics

  1. Electroencephalogram (EEG) Indications
    1. Emergent EEG if Status Epilepticus (even if treated)
    2. Routine EEG (preferably within 48 hours)
      1. Recommended for most cases of new onset Seizures that are unprovoked
      2. Attempt to schedule EEG soon after event (i.e. within 7 days of event)
        1. EEG has highest Test Sensitivity in first 24 hours after Seizure
        2. EEG abnormalities double the risk of Seizure recurrence and change management
      3. EEG is normal in 10 to 50% of true Epilepsy cases
        1. Repeat as a sleep-deprived EEG if high level of suspicion, but negative EEG
  2. Lumbar Puncture indications
    1. CNS Infection suspected (fever, Meningitis)
      1. Seizure not consistent with simple Febrile Seizure
      2. Unlikely to be useful in awake, alert patients without significant infectious findings
    2. Immunocompromised patient
    3. Age under 6 months
    4. Severe, Thunderclap Headache (evaluate for Subarachnoid Hemorrhage)
    5. Unvaccinated
    6. Altered Mental Status
  3. Consider cardiovascular evaluation in older patients (for Syncope)
    1. Chest XRay
    2. Electrocardiogram
    3. Echocardiogram
    4. Holter Monitor
    5. Carotid Ultrasound
  4. Consider Sepsis evaluation if signs toxicity or SIRS criteria (or qSOFA Score)
    1. Lumbar Puncture
    2. Urinalysis and Urine Culture
    3. Blood Culture
    4. Other source evaluation (Chest XRay)

VIII. Imaging: Structural study

X. Evaluation

  1. Indications for Electrolyte and metabolic testing
    1. Age under 6 months (aside from simple Febrile Seizure)
    2. Encephalopathy or coma
    3. Developmental Delay
    4. Persistent acidosis
    5. Findings out of proportion to level of Dehydration or other predisposing factors
  2. Indications for Sepsis or CNS Infection evaluation
    1. Fever AND
    2. Other signs of more significant infection
      1. Toxicity or SIRS criteria
      2. Meningismus
      3. Persistent Altered Mental Status (beyond post-ictal period)
  3. Other indications for extensive evaluation (labs, imaging, diagnostics)
    1. Status Epilepticus

XI. Management: General

  1. See Status Epilepticus for acute Seizure management
  2. First-time Seizures do not require admission in most cases
    1. Exceptions are described below
  3. Provoked Seizures typically require no antiepileptic medications if returned to baseline
    1. Treat underlying cause (e.g. Alcohol Withdrawal)
    2. However, some Provoked Seizures (e.g. Intracranial Hemorrhage) receive Seizure Prophylaxis
  4. Unprovoked first Seizures are typically not given prophylaxis unless high risk for recurrence (if returned to baseline)
    1. See Seizure Prophylaxis
    2. Discuss with neurology
    3. Only 9% of first-time Seizures have recurrence in first 6 weeks while awaiting clinic follow-up
      1. Breen (2005) Postgrad Med J 81(961): 725-8 [PubMed]
    4. Seizure Prophylaxis reduces recurrence risk by 35% within first 2 years after first Seizure
      1. Seizure Prophylaxis does improve the chances of driving at 2 years
      2. However, benefit of Seizure Prophylaxis falls over time until marginal benefit at 3 to 5 years
      3. Seizure Prophylaxis has adverse effects, and does not improve quality of life or reduce mortality
      4. Krumholz (2015) Epilepsy Curr 15(3): 144-52 [PubMed]
  5. Driving restriction after Seizure
    1. Typically 3 to 6 month driving suspension required following most recent Seizure
    2. Mandatory reporting varies by U.S. State
    3. Epilepsy foundation
      1. http://www.efa.org
  6. Anticipatory Guidance
    1. Risk of recurrent Seizure (see below)
    2. Subsequent Seizure management
    3. Avoid driving (see above)
    4. Avoid swimming or bathing alone
    5. In some cases, rectal Diazepam may be provided for a recurrent episode

XII. Management: Disposition

  1. Hospitalization Indications
    1. Acute anticonvulsant management required at presentation (Status Epilepticus management)
    2. Prolonged postictal phase or Altered Mental Status >1 hour following Seizure
    3. Abnormal diagnostic evaluation (e.g. labs, neuroimaging)
    4. Infants with non-Febrile Seizure
    5. Injuries sustained during the Seizure
    6. Limited access to outpatient care
  2. Discharge Indications
    1. Return to baseline mental status
    2. Normal Neurologic Exam

XIII. Prognosis

  1. Recurrence risk after first, unprovoked, non-Febrile Seizure in children
    1. Recurrence at one year: 20-30%
    2. Recurrence at 10 years: 50%
    3. Recurrence after a second non-Febrile Seizure: 75%
    4. Major (2007) Pediatr Rev 28(11): 405-14 [PubMed]
  2. Recurrence risk of Seizure in adults
    1. Recurrence at one year: 65%
    2. Recurrence at two years: 76%
  3. Predictors of recurrent Seizure
    1. EEG with epileptiform changes
    2. Unprovoked or remote provocative factor (e.g. prior CVA)
    3. Nocturnal Seizures
    4. Febrile Seizure history
    5. Abnormal brain imaging
    6. Neurologic abnormalities
      1. Focal deficits or underlying congenital or acquired chronic disorders
      2. Severe Head Trauma
      3. Cerebral Palsy
      4. Encephalopathy
      5. Space occupying CNS Lesion
      6. Todd's Paralysis history
  4. Predictors of no recurrence of Seizure
    1. Normal EEG (recurrence risk 20-25% by 2 years)
    2. No Seizure within 1 year of first Seizure
    3. Acute provocative factors (e.g. metabolic disturbance)
  5. References
    1. Hart (1990) Lancet 336(8726): 1271-4 [PubMed]
    2. Chin (2006) Lancet 368(9531): 222-9 [PubMed]

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