II. History: Present Ilness

  1. Careful review of events leading up to Seizure
    1. Provoked (e.g. Alcohol Withdrawal, Head Trauma) or unprovoked Seizure?
  2. Number of Seizures in the prior 24 hours
  3. Presence of prodromes or auras
  4. Description of Seizure by reliable witness including focal aspects
    1. Unilateral movements
    2. Eye Deviation
    3. Head turning
  5. Time from onset to cessation of motor activity
  6. Postictal duration and observations

III. History: Past Medical History

  1. Febrile Convulsions
  2. Head Injury
  3. Vascular disease
    1. Cerebrovascular Accidents
    2. Coronary Artery Disease
  4. Cancer
  5. Infectious disease
  6. Sleep Disorder
  7. Medications (including over the counter, and Herbals)

IV. History: Family

  1. Febrile Convulsions
  2. Epilepsy in siblings, parents, or close relatives
  3. History of neurogenic disorders

V. History: Social

  1. Travel
  2. Occupation
  3. Substance Abuse

VI. Exam

  1. Injury pattern
    1. Oral Lacerations (especially lateral Tongue bites)
    2. Urinary Incontinence
    3. Burn injuries are common
  2. Cardiovascular exam
  3. Skin exam
  4. Neurologic Exam
    1. Focal postictal deficits
    2. Focal neurologic deficits after recovery
    3. Neuropsychological evaluation

VII. Labs: First-line indicated in most patients

  1. Serum Glucose
  2. Serum Sodium
  3. Urine Pregnancy Test (in women of child-bearing age)

VIII. Labs: As indicated by presentation

  1. Complete Blood Count
  2. Serum electrolytes (especially Serum Sodium), calcium, Magnesium, and phosphorus
  3. Serum Glucose
  4. Renal Function tests
    1. Creatinine
    2. Blood Urea Nitrogen
  5. Liver Function Tests
  6. Erythrocyte Sedimentation Rate (ESR)
  7. Ammonia level (in Cirrhosis history)
  8. Urine Toxicology Screening
  9. Serum drug levels (as indicated)
  10. Serum Prolactin is not typically helpful
    1. Increased in 40-60% within 20 minutes of Seizure

IX. Diagnostics

  1. Electroencephalogram (EEG) Indications
    1. Emergent EEG if Status Epilepticus (even if treated)
    2. Routine EEG (preferably within 48 hours)
      1. Recommended for most cases of new onset Seizures
      2. EEG is normal in 50% of true Epilepsy cases
        1. Repeat as a sleep-deprived EEG if high level of suspicion, but negative EEG
  2. Lumbar Puncture indications
    1. CNS Infection suspected (fever, Meningitis)
    2. Immunocompromised patient
    3. Age under 6 months
    4. Severe, Thunderclap Headache (evaluate for Subarachnoid Hemorrhage)
  3. Consider cardiovascular evaluation in older patients (for Syncope)
    1. Chest XRay
    2. Electrocardiogram
    3. Echocardiogram
    4. Holter Monitor
    5. Carotid Ultrasound

X. Imaging: Structural study

XII. Management

  1. See Status Epilepticus for acute Seizure management
  2. First-time Seizures do not require admission
  3. Provoked Seizures typically require no antiepileptic medications if returned to baseline
    1. Treat underlying cause (e.g. Alcohol Withdrawal)
  4. Unprovoked first Seizures are typically not given prophylaxis unless high risk for recurrence (if returned to baseline)
    1. See Seizure Prophylaxis
    2. Discuss with neurology
    3. Only 9% of first-time Seizures have recurrence in first 6 weeks while awaiting clinic follow-up
      1. Breen (2005) Postgrad Med J 81(961): 725-8 [PubMed]
  5. Driving restriction after Seizure
    1. Typically 6 month driving suspension required following most recent Seizure
    2. Mandatory reporting varies by U.S. State
    3. Epilepsy foundation
      1. http://www.efa.org

XIII. Prognosis

  1. Recurrence risk after first, unprovoked, non-Febrile Seizure in children
    1. Recurrence at one year: 20%
    2. Recurrence at 10 years: 50%
  2. Recurrence risk of Seizure in adults
    1. Recurrence at one year: 65%
    2. Recurrence at two years: 76%
  3. Predictors of recurrent Seizure
    1. EEG with epileptiform changes
    2. Unprovoked or remote provocative factor (e.g. prior CVA)
    3. Neurologic abnormalities
      1. Focal deficits or underlying congenital or acquired chronic disorders
      2. Severe Head Trauma
      3. Cerebral Palsy
  4. Predictors of no recurrence of Seizure
    1. Normal EEG (recurrence risk 20-25% by 2 years)
    2. No Seizure within 1 year of first Seizure
    3. Acute provocative factors (e.g. metabolic disturbance)
  5. References
    1. Hart (1990) Lancet 336(8726): 1271-4 [PubMed]

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