Single Seizure Evaluation

Aka: Single Seizure Evaluation, Seizure Evaluation, First Seizure Evaluation

II. History: Present Ilness

  1. Careful review of events leading up to Seizure
    1. Provoked (e.g. Alcohol Withdrawal, Head Trauma) or unprovoked Seizure?
  2. Number of Seizures in the prior 24 hours
  3. Presence of prodromes or auras
  4. Description of Seizure by reliable witness including focal aspects
    1. Unilateral movements
    2. Eye Deviation
    3. Head turning
  5. Time from onset to cessation of motor activity
  6. Postictal duration and observations

III. History: 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)

IV. History: Family

  1. Febrile Convulsions
  2. Epilepsy in siblings, parents, or close relatives
  3. History of neurogenic disorders

V. History: Social

  1. Travel
  2. Occupation
  3. Substance Abuse

VI. Exam

  1. Injury pattern
    1. Oral Lacerations (especially lateral Tongue bites)
    2. Urinary Incontinence
    3. Burn injuries are common
  2. Cardiovascular exam
  3. Skin exam
  4. Neurologic Exam
    1. Focal postictal deficits
    2. Focal neurologic deficits after recovery
    3. Neuropsychological evaluation

VII. 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)

VIII. 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

IX. 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
      2. EEG is normal in 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. 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)

X. Imaging: Structural study

  1. See Seizure Indications for Neuroimaging

XI. Differential Diagnosis

  1. See Seizure Causes
  2. Syncope
  3. Febrile Seizure
  4. Infantile Spasms
  5. Pediatric Spells
  6. Psychogenic Nonepileptic Seizure

XII. 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

XIII. 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)
  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]
  5. Driving restriction after Seizure
    1. Typically 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

XIV. 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

XV. 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. 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]

XVI. References

  1. Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9
  2. (2014) Ann Emerg Med 63(4): 437-47 [PubMed]
  3. Adams (2007) Am Fam Physician 75:1342-48 [PubMed]
  4. Wilden (2012) Am Fam Physician 86(4): 334-40 [PubMed]

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