A 50 year-old male with no prior medical history presents with an episode of whole-body shaking concerning for first time seizure. On initial evaluation patient is confused. He has dried blood on his lips and obvious urinary incontinence. His vital signs are stable. Shortly after he is much more awake and feels back to his baseline. His neuro exam is unremarkable. What do you do next?

Take further history to assess for causes of provoked seizure:

  -  Traumatic head injury, coagulopathy, anticoagulation - intracranial hemorrhage

  -  Headaches - mass lesion

  -  Pregnancy - ecclampsia

  -  Infection - meningitis, encephalitis, abscess

  -  Metabolic abnormalities - hyponatremia, hypernatremia, hypoglycemia, hyperglycemia

  -  Hypoxia - anoxic-ischemic injury

  -  Toxin exposure - meds (isoniazid, lidocaine, antidepressants, theophylline), cocaine, Gyromitra spp of mushroom

  -  Withdrawal from alcohol or benzodiazepines

  -  Uncontrolled hypertension - hypertensive encephalopathy

Perform a detailed physical exam:

  -  Detailed neuro exam

  -  Traumatic injuries, such as posterior shoulder dislocation

Consider other (non-seizure) diagnoses:

  -  Syncope

  -  Pseudoseizure

  -  Movement disorder

Obtain further workup:

  -  All patients: point of care blood glucose

  -  Women of childbearing age: pregnancy test

  -  ACEP recommends additionally at a minimum obtaining serum sodium level

Advanced imaging:

  -  CT head in ED is controversial

  -  Per Rosen’s textbook, CT head should be obtained in ED if: new focal deficit, persistent altered mental status, fever, recent trauma, persistent headache, history of cancer, anticoagulant use, suspicion or known history of AIDS, age >40, presence of partial complex seizure

  -  Most other patients suitable for outpatient follow-up and imaging

Resolution of case: 

A blood glucose level and chemistry were obtained which were normal. A CT head was obtained which was unremarkable. The patient had no further episodes of seizures while in the ED and was completely back to neurologic baseline. The patient typically drives so you remember to instruct the patient that he is not able to drive until he is cleared by neurologist or primary physician, and you send his information to the Department of Motor Vehicles. You remind the patient not to operate heavy machinery or go swimming. You set up follow up with neurology as an outpatient. 

References:

1. Kornegay, J. “Seizures.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Ed. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016. 
2. McMullan J et al. Seizure disorders, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2010, (Ch) 102: p 1375-1385.
3. Pillow, et al. “Best Practices for Seizure Management In the Emergency Department.” ACEP Now, 3 Feb. 2015, www.acepnow.com/article/best-practices-seizure-management-emergency-department/?singlepage=1.