II. History: Present Ilness
- Careful review of events leading up to Seizure
- Provoked (e.g. Alcohol Withdrawal, Head Trauma) or unprovoked Seizure?
- Number of Seizures in the prior 24 hours
- Presence of prodromes or auras
- Description of Seizure by reliable witness including focal aspects
- Unilateral movements
- Eye Deviation
- Head turning
- Time from onset to cessation of motor activity
- Postictal duration and observations
III. History: Past Medical History
- Febrile Convulsions
- Head Injury
- Vascular disease
- Cancer
- Infectious disease
- Sleep Disorder
- Medications (including over the counter, and Herbals)
IV. History: Family
- Febrile Convulsions
- Epilepsy in siblings, parents, or close relatives
- History of neurogenic disorders
V. History: Social
- Travel
- Occupation
- Substance Abuse
VI. Exam
- Injury pattern
- Oral Lacerations (especially lateral Tongue bites)
- Urinary Incontinence
- Burn injuries are common
- Cardiovascular exam
- Skin exam
-
Neurologic Exam
- Focal postictal deficits
- Focal neurologic deficits after recovery
- Neuropsychological evaluation
VII. Labs: First-line indicated in most patients
- Fingerstick Glucose (all patients)
- Serum Sodium
- Urine Pregnancy Test (in women of child-bearing age)
VIII. Labs: As indicated by presentation (e.g. dehydration, toxic ingestion)
- Complete Blood Count
- Serum Electrolytes (especially Serum Sodium), Calcium, Magnesium, and Phosphorus
- Indicated for gastrointestinal losses, poor oral intake or other suspected cause
- Especially consider in infants with new onset Seizure
-
Serum Glucose
- At minimum, check a fingerstick Glucose as above
- Renal Function tests
- Liver Function Tests
- Erythrocyte Sedimentation Rate (ESR)
- Ammonia level (in Cirrhosis history)
- Urine Toxicology Screening
- Serum drug levels (as indicated)
-
Serum Prolactin is not typically helpful
- Increased in 40-60% within 20 minutes of Seizure
IX. Diagnostics
-
Electroencephalogram (EEG) Indications
- Emergent EEG if Status Epilepticus (even if treated)
- Routine EEG (preferably within 48 hours)
-
Lumbar Puncture indications
- CNS Infection suspected (fever, Meningitis)
- Seizure not consistent with simple Febrile Seizure
- Immunocompromised patient
- Age under 6 months
- Severe, Thunderclap Headache (evaluate for Subarachnoid Hemorrhage)
- Unvaccinated
- Altered Mental Status
- CNS Infection suspected (fever, Meningitis)
- Consider cardiovascular evaluation in older patients (for Syncope)
- Consider Sepsis evaluation if signs toxicity or SIRS criteria (or qSOFA Score)
- Lumbar Puncture
- Urinalysis and Urine Culture
- Blood Culture
- Other source evaluation (Chest XRay)
X. Imaging: Structural study
XI. Differential Diagnosis
XII. Evaluation
- Indications for Electrolyte and metabolic testing
- Age under 6 months (aside from simple Febrile Seizure)
- Encephalopathy or coma
- Developmental Delay
- Persistent acidosis
- Findings out of proportion to level of dehydration or other predisposing factors
- Indications for Sepsis or CNS Infection evaluation
- Fever AND
- Other signs of more significant infection
- Toxicity or SIRS criteria
- Meningismus
- Persistent Altered Mental Status (beyond post-ictal period)
- Other indications for extensive evaluation (labs, imaging, diagnostics)
XIII. Management: General
- See Status Epilepticus for acute Seizure management
- First-time Seizures do not require admission in most cases
- Exceptions are described below
- Provoked Seizures typically require no antiepileptic medications if returned to baseline
- Treat underlying cause (e.g. Alcohol Withdrawal)
- Unprovoked first Seizures are typically not given prophylaxis unless high risk for recurrence (if returned to baseline)
- See Seizure Prophylaxis
- Discuss with neurology
- Only 9% of first-time Seizures have recurrence in first 6 weeks while awaiting clinic follow-up
- Driving restriction after Seizure
- Anticipatory Guidance
XIV. Management: Disposition
- Hospitalization Indications
- Acute anticonvulsant management required at presentation (Status Epilepticus management)
- Prolonged postictal phase or Altered Mental Status >1 hour following Seizure
- Abnormal diagnostic evaluation (e.g. labs, neuroimaging)
- Infants with non-Febrile Seizure
- Injuries sustained during the Seizure
- Limited access to outpatient care
- Discharge Indications
- Return to baseline mental status
- Normal Neurologic Exam
XV. Prognosis
- Recurrence risk after first, unprovoked, non-Febrile Seizure in children
- Recurrence at one year: 20-30%
- Recurrence at 10 years: 50%
- Recurrence after a second non-Febrile Seizure: 75%
- Major (2007) Pediatr Rev 28(11): 405-14 [PubMed]
- Recurrence risk of Seizure in adults
- Recurrence at one year: 65%
- Recurrence at two years: 76%
- Predictors of recurrent Seizure
- EEG with epileptiform changes
- Unprovoked or remote provocative factor (e.g. prior CVA)
- Nocturnal Seizures
- Febrile Seizure history
- Neurologic abnormalities
- Focal deficits or underlying congenital or acquired chronic disorders
- Severe Head Trauma
- Cerebral Palsy
- Encephalopathy
- Space occupying CNS Lesion
- Todd's Paralysis history
- Predictors of no recurrence of Seizure
- References
XVI. References
- Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9
- (2014) Ann Emerg Med 63(4): 437-47 [PubMed]
- Adams (2007) Am Fam Physician 75:1342-48 [PubMed]
- Wilden (2012) Am Fam Physician 86(4): 334-40 [PubMed]