First Seizure

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



Background

  • Population studies: 4-7% lifetime risk of one seizure, 1% chance of epilepsy.
  • 1.2% of ED attendances (of these 1/4 are first seizures).

Seizures divided into:

  • "Unprovoked" (about 70% of first seizures).
  • "Provoked" by an acute brain insult or pre-existing lesion e.g.
    • electrolyte disturbance, hypoglycaemia
    • head injury, febrile illness, meningitis/encephalitis
    • alcohol and drug excess or withdrawal (generally younger patients)
    • stroke (older age group)

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 following 1st seizure

CUH

  • 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 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.

MUH

  • 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.

Algorithm

First Seizue Algorithm Cork University Hospital Dec 2010

CUH CDU Discharge checklist

  • Check ECG in everyone (you are already doing this).
  • EEG & Epilepsy protocol MRI in those you see fit.
  • If CT scan shows clear structural injury (TBI etc), then MRI probably not needed.
  • If a convulsive seizure (particularly if >2 minutes) start Levetiracetam 250mg bid a 1 week, then increase to 500mg bid (Dr. D Costello Dec 2012).
  • Consider giving family a prescription for PRN buccal midazolam 10mg if patient presents with 1st prolonged convulsion.

Treatment

Anticonvulsants

  • In general, seizures provoked only by alcohol withdrawal, metabolic or drug-related causes, or sleep deprivation should not be treated with antiepileptic drugs.
  • Anticonvulsant treatment is indicated only if there is an unacceptable risk of further seizures, which can be determined by 3 factors:
  1. Was event "provoked" or "unprovoked"?
  2. Is EEG normal or does it show (i) focal slowing or (ii) epileptiform discharges. The latter 2 types of EEG finding.s 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.

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. Please see "Driving".

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.



Content by Dr Íomhar O' Sullivan 15/11/2010 Dr Daniel Costello (CUH) 07/12/2010. Last review 24/04/16.