First Seizure

College of Emergency Medicine 2010 GEM NET publication - Mx of First Seizure

Background

Seizures divided into

Overall, the risk of recurrence is 30–40% (max in the first 6/12 and falls to <10% after 2 years).

Recurrence more likely if brain imaging (CT or MRI) and/or EEG are abnormal.

Collateral history is the most important ‘test’ in evaluating patients with suspected seizures

Investigations

  • Record serum Glucose, U&E (hyponatraemia)
  • Consider Ca++, Mg++ to identify other pathology
  • ECG in all cases (Troponins if doubt about seizure from collateral history); confirm QT interval
  • In MUH, please record toxicology screen
  • Please record pregnancy test in women
  • Chest x-ray and lumbar puncture as clinically indicated

EEG

EEG should only be requested by the EM consultant (usually after review in the CDU)

 

Imaging

  • CT (or MRI) immediately if SOL suspected particularly if:
    • History of head injury trauma or risk of ICH (coagulopathy/Warfarin/alcoholism)
    • New focal deficit, persistent altered mentation or meningism
    • Partial or focal onset seizure
    • Persisting headache
    • History of malignancy, immunocompromise or HIV
  • Patients with repeated presentations to ED with seizures do not warrant repeated imaging studies unless new clinical signs or circumstances arise or obtundation is persistent
  • MRI (preferable to CT) if patient has fully recovered - request ‘Epilepsy Protocol’ MRI study.

Disposition

Disposition following First Seizure

CUH

MUH
  • Confirm neurological recovery, no neuro deficit
  • Record serum Glucose, U&E (hyponatraemia)
  • Consider Ca++, Mg++ to identify other pathology
  • ECG in all cases (troponins if doubt about seizure from collateral history); confirm QT interval
  • Admit to CDU if patient has recovered, no neurological deficit and normal glucose / ECG
  • If seizure was "unprovoked" and/or patient is at significant risk of further seizures, refer for inpatient Neurology Consultation or ‘First Seizure’ clinic
  • If seizure occurred in setting of heavy alcohol intake, request Alcohol Counselling service assessment.
  • Consider CDU (EM consultant) or medical admission if alcoholism, poor social circumstances or those without a responsible adult to stay with
  • Confirm neurological recovery, no neuro deficit
  • Record Glucose, U&E (hyponatraemia)
  • Consider Ca++, Mg++ to identify other pathology
  • ECG in all cases (troponins if doubt about seizure from collateral history); confirm QT interval
  • In MUH please record toxicology screen
  • Please record pregnancy test in women
  • Admit under on-call Neurology Team (medical) in MUH

AlgorithmFirst Seizue Algorithm Cork University Hospital Dec 2010

Treatment and advice

Anticonvulsants

  1. Was event "provoked" or "unprovoked"? "Unprovoked" events are more likely to recur
  2. Is EEG normal or does it show (i) focal slowing or (ii) epileptiform discharges. The latter 2 types of EEG findings would predict recurrence.
  3. Is imaging normal? Abnormal imaging associated with increased risk of further seizures

Driving and lifestyle advice

Driving. Patient should stop driving immediately. They should inform their insurance company (car insurance will be invalid) and GP. A medical report form (D501) will be required before they can return to driving. Some (unprovoked) can resume driving after six months (of seizure free) but will require detailed assessment by a neurologist. More information is available at the RSA website site, particularly Medical Aspects of Driver Licensing.

Occupation. The patient should inform their employer. In most cases, there will be no impact on work. If their occupation involves driving, working at heights or working with machinery, there may be some restrictions.

Recreation. Having had a seizure should not stop patients from doing the things they enjoy, although sensible safety precautions do need to be taken. They should be advised not to swim alone, not to lock the bathroom door when bathing, or bathing infants alone.

References and Links