1st time seizure workup

[iaskdumbquestions]

This is something I have seen done differently at the many places I've rotated. Let's say a first time, unprovoked seizure is brought into your clinic, or the ED. What do you do for a workup?

We'll assume that 1) it's truly unprovoked, 2) patient is back to baseline, 3) no other medical history, 4) only 1 seizure

I have seen everything from CT, EEG, labs, Neurology consult to labs and discharge with PCP follow up. So let me ask you what your approach is. Do you think 1 unprovoked seizure requires imaging, Neuro consult and EEG? If you were in your clinic or working in an ED, what would your approach be?

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[Telamir]

It depends on the age of the patient where you get the most common causes (malignancy, vascular lesions, stroke, etc) and that tailors the workup a little bit. Also if history is available you want to try to figure out if it is truly a "GTC" or if there was some focal features which would complicate things. In general though:

1) General labs (CBC, CMP, TSH, LFTs) etc. Urine drug screen at least
2) EEG (if abnormal biggest predictor for epilepsy down the road)
3) MRI Brain W/WO CST

I'm sure others will add more. Also there are Continuum articles written on this subject, I think.

 

[deathmerchant]

If it was a Generalized seizure And there is some provoking factor And the exam is normal And the patient returns to normal pretty fast, I will send the patient out from ER.

If there are any other red flags- Definite Focal onset Seizure, Prolonged post ictal, Abnormal Exam; I will either admit overnight and get MRI, EEG and labs or if patient seems stable and compliant - get labs and CTH in ER and get outpatient EEG and MRI as soon as possible.

 

[oopsy]

Agree with above. At the institution where I trained, it was very easy to get an MRI and EEG in the ED, so we did for most of these patients. Total overkill. In every other place, I would do it as deathmerchant (ominous name) listed above which is a rational approach I think many folks go by. These are the labs I check.

- CMP, CBC, UA w/ reflex, Serum Osm, Urine toxicology, TSH,
- CK, lactic acid <if I don't buy it was a GTC, didnt use prolactin much based on its limitations>
- CXR
- Afebrile now; if febrile, BCx, LP

Everyone (with new seizure) should get a NCHCT on arrival b/c they can seize from intracranial badness. Interval MRI/EEG is reasonable as an outpatient with the conditions listed above, if not met, would insist on workup being done prior to discharge.

Most important thing, document cautionary measures - advise patient to not drive, swim alone, operate heavy machinery until medically cleared to do so by primary care physician or neurologist.