Patient Disposition
The management and ultimate disposition of a patient with a seizure depends on the underlying cause, and whether the patient has neurologic deficits and/or is back to their baseline mental status. For patients presenting with a first-time seizure and have returned to baseline, the American College of Emergency Physicians’ (ACEP) clinical policy states that precipitating medical conditions should be identified and addressed accordingly if it is a provoked seizure.
If patients present with a first-time unprovoked seizure and do not have evidence of brain injury or neurologic disease (ie, persistent altered mental status or abnormal neurologic examination), then the EP does not need to initiate antiepileptic medications. If there is evidence of neurologic disease or brain injury in an unprovoked seizure, then the EP may either choose to initiate antiepileptic medications or choose to defer, pending consultation with neurology. This group of patients (first-time unprovoked seizure back to baseline) do not need to be admitted to the hospital under the premise that they have a negative workup, to include glucose, CT scan (if indicated), ECG, CBC, and CMP. They must also have normal vital signs, be advised regarding seizure precautions such as not to drive until further medical evaluation (with duration perhaps being set by state law), and have good social support. They will require close follow up for further evaluation and definitive diagnosis, which may include head imaging, if not already performed in the ED, and EEG.
Patients with a history of epilepsy can have recurrent seizures that are either provoked or unprovoked. If the seizure appears clinically similar to their previous seizures, then causes that could lower the seizure threshold should be investigated; including compliance with antiepileptic medications (obtain serum levels), infection (urinalysis and/or chest X-ray), sleep deprivation, electrolyte imbalances, or medications known to lower seizure threshold (eg, certain antibiotics such as fluoroquinolones, antidepressants such as bupropion and venlafaxine, and antipsychotics such as clozapine). These underlying causes should be treated accordingly. If a patient has been noncompliant with their medications, a loading dose can be given in the ED, although there are no definitive studies that either support or debunk this practice. If it is a true, unprovoked seizure and the patient is compliant with their antiepileptic medication, it is reasonable to discuss medication regimen changes with the patient’s neurologist.17A patient that presents with seizure-like activity and does not return back to their baseline mental status requires a more immediate and comprehensive evaluation. Persistent altered mental status has a vast differential diagnosis, and is outside the scope of this article, but if seizures were part of the clinical presentation, the possibility of non-convulsive epilepticus should be considered. These patients may require treatment with medications (usually IV benzodiazepines), admission to the hospital, neurology consultation, EEG, imaging (CT vs MRI), and +/- lumbar puncture depending on the clinical scenario.
Status epilepticus will be further discussed in part 2 of this review.