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Seizure Assessment

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Seizure Assessment:

This section includes basic assessment for first seizure, recurrent seizures w/ known epilepsy, or what to do if patient does not return to baseline

First Seizure

History of event:

  • Seizure provoking risk factors

    • Birth hx, developmental hx, febrile seizure, CNS infection, head trauma, neoplasm, CNS malformation, prior CVA, family history of seizures

  • Ictal Symptoms

    • Aura (based on localization): Deja vu, fear, “spacing out”, rising sensation, nausea/vomiting, abnormal taste/smell, myoclonus etc.

    • LOC, falling, head injury, movements of head/face/limbs, automatisms, eye/head movements, tongue biting, bladder/bowel incontinence

    • Eyewitness description

  • Duration

  • Postictal: amnesia, Todd’s, aphasia, lethargy, confusion

  • Comprehensive review of all prior AEDs

  • Comprehensive review of medications as these can lower seizure threshold: SSRIs, Wellbutrin, Antibiotics (carbapenems, Quinolones), Tramadol, INH, Tricyclic antidepressants

  • Social history as these substances can lower seizure threshold: Cocaine/Sympathomimetics, Alcohol Withdrawal, Organophosphates, Synthetic Marijuana/K2/Spice

Workup in ED:

  • FSG, CBC, Chem-7, Mg, Phos, LFTs, AED levels
  • Consider Utox, EtOH level, K2 assay, UA, CXR, pregnancy test, LP

Recurrent Seizure in Patient with Known Epilepsy

  • Ask if event was same or different from prior seizures

  • Probe for factors that lower threshold for seizures, including: Fever, sleep deprivation, excessive stimulant use, withdrawal from benzos/EtOH, hypoglycemia, electrolyte disturbance, hypoxia, infection, acute medical/neurologic illness (CVA, trauma, CNS infection), medication changes

  • Check appropriate labs & AED levels (only CBZ, PHT, VPA, and PHB available acutely)

Not Returning to Baseline after Seizure

Most common reasons are excess benzo administration and prolonged post-ictal period, but must rule out other causes...

  • Make sure patient isn’t still seizing (look for subtle abnormal limb and eye movement, gaze deviation, fluctuating arousal, or lack of any improvement).

  • If you have any concerns for ongoing seizures, call your senior or attending and EEG tech to connect patient. Patient cannot be in the ED for EEG. NSICU fellow/NEMAT hotline can also help with patients who may be in status epilepticus.

  • Get HCT if not already done

  • Consider LP if you have any concerns for meningitis/encephalitis/SAH

  • You will likely need to admit patients who don’t return to baseline quickly for closer monitoring. They should be admitted to neuro if there is no medical reason for seizure (w/d, infection, electrolyte abnormality, etc).