First time seizure = admit?

[WilcoWorld]

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How many of you admit first time seizures?

I know that when I started residency I was very surprised to find out that a first time seizure does not require admission if the work up (neuro exam, BMP, CT head, +/- tox screen) is negative and there are no concerning historical features. Now that I've read a bit about it and seen it many times I am much more comfortable with this. However, family members are often shocked when I'm sending someone home, and every time I've gotten a neuro consult they have recommended admission (doesn't it seem like they ALWAYS recommend admission & the same battery of tests, no matter the complaint?). When I ask why, there is almost never a concern about morbidity / mortality (after you've told them not to drive) to warrant the admission - it's for a bunch of work up that in my opinion could be done as an outpatient.

So, since the EM and the Neuro people seem to differ on this at the place I trained I was wondering what people do elsewhere...

 

[deleted52758]

i think it's all about what sort of resources your hospital has. for our patients, it would take about two months to get them an appropriate workup as an outpatient, which is obviously way too long, so we end up admitting the majority of first time seizures. But if i had a neurologist, who could arrange the eeg and other thigns in a timely fashion, i probably wouldnt admit all of them.

 

[WilcoWorld]

That seems like a very reasonable answer. However, it's begs the question, how long is too long? 3 days, a week, a month?

 

[DrQuinn]

I admit all first time seizures. Though you can say "don't drive, don't operate heavy machinery, etc, until you are seen by a neurologist," but neuro outpaitent appointments are weeks-months for a new unestablished patient. As well as, "the doctor never told me to walk around my house with scissors pointed at my abdomen, now I had a seizure now I have no guts left...." TOo high risk.

First time diabetes, not in DKA? No big thing. Here's some metformin, follow up with your primary.

First time seziures? too many bad sequelae, you need admission and atleast an initial visit by a neurologist.

Q

 

[roja]

I think you will find that management depends on the environment you are in. If you have a responsible patient, can get follow up, etc etc.

I have been where I sent them home and where I have admitted.

 

[emergiQ]

I admit all first time seizures. Though you can say "don't drive, don't operate heavy machinery, etc, until you are seen by a neurologist," but neuro outpaitent appointments are weeks-months for a new unestablished patient. As well as, "the doctor never told me to walk around my house with scissors pointed at my abdomen, now I had a seizure now I have no guts left...." TOo high risk.

First time diabetes, not in DKA? No big thing. Here's some metformin, follow up with your primary.

First time seziures? too many bad sequelae, you need admission and atleast an initial visit by a neurologist.

Q

Generally, I agree with Q -- too many high risk things in a modern household to send them out with uncertain follow up. Plus, besides another seizure being dangerous, I am worried about the other big bad reasons for seizures (like SOL) which might need an MRI to pick up. Sure, a week or two isn't going to make a difference in terms of cancer diagnosis, but a couple of months might. And there's other things besides cancer under SOL that should be sorted out on the order of days to weeks rather than months.

I have, however, sent them home after conferring with a neurologist who slots them in as an add-on at clinic in a reasonable time frame (two weeks is my limit, but hey, if they do something like drive a truck for a living, even this might be too prohibitively long to go without driving and income for some families) +/- the neurologist pulling strings to fast-track an outpatient MRI. The neurologist doesn't necessarily have to even come in let alone admit them if he/she organizes an MRI and a follow up on an outpatient basis with 14 days in my book. But if I get a non-commital response from a neurologist when I try this grand-bargain (or certainly if there is ANY concern that it's infective in nature) I admit 'em.

Good question, OP

 

[Seaglass]

I usually send them home if their workup is negative.

 

[matt_mt19]

Attached you'll find an article from the NEJM discussing management similar to your question stem. It discussing initial therapy and work-up, written from the neurology perspective. Sometimes find it interesting to see their standard of care, which influences ours.

Initial Management... French, et.al
NEJM 2008; 359:166-76

 

[gutonc]

Not sure about admitting first seizures by default, but for all that is good and holy, if you're going to admit them to medicine don't get all pissy and hang up when we ask you what neuro thought about the case. I don't mind taking care of them but, assuming all the lytes are WNL, I'm basically babysitting until neuro takes over so at least do me the favor of letting them know about the patient.

This happened to me twice on my last MICU month, both by attendings who thought that a neuro consult for new-onset GTCs w/o obvious cause was something that could wait until the morning. If they need a unit bed, they need neuro on board.

 

[bulgethetwine]

Not sure about admitting first seizures by default, but for all that is good and holy, if you're going to admit them to medicine don't get all pissy and hang up when we ask you what neuro thought about the case. I don't mind taking care of them but, assuming all the lytes are WNL, I'm basically babysitting until neuro takes over so at least do me the favor of letting them know about the patient.

This happened to me twice on my last MICU month, both by attendings who thought that a neuro consult for new-onset GTCs w/o obvious cause was something that could wait until the morning. If they need a unit bed, they need neuro on board.

Why were they being admitted to the MICU anyway?

And did you misplace your card with all the hospital consult numbers on it?

 

[EM2BE]

Does age of the pt play a role in whether you admit? If it's a child and can get the consult within a few weeks, would you be more likely to send them home than an adult? I figure adults kind of rely on working, so the faster the diagnosis and etiology the better, but with kids it can go either way (they don't have to drive, etc).

 

[emergentmd]

Unless there is some odd presentation or circumstance to the seizure, I send them home with a neg CT head and lytes. I don't even do a tox screen as this doesn't change my management.

I don't really see any reason to admit for a first time seizure that is uncomplicated.

If we start to admit patients just because there are not very good follow up, then I should admit all new onset HTN b/c I can't be sure that they will follow up. How about first time syncope or chest pain in a young person, as I can't be sure they will follow up with cardiology. Or how about the abdominal pain of unclear etiology, as i have no clue that they will follow up for a recheck..... cause it may be an appy.

I give them the on call neurologist and it is there responsibility to follow up. I also tell them to come back if they have any issues.

We are not responsible for fixing outpt care issues.

 

[GeneralVeers]

Unless there is some odd presentation or circumstance to the seizure, I send them home with a neg CT head and lytes. I don't even do a tox screen as this doesn't change my management.

I don't really see any reason to admit for a first time seizure that is uncomplicated.

If we start to admit patients just because there are not very good follow up, then I should admit all new onset HTN b/c I can't be sure that they will follow up. How about first time syncope or chest pain in a young person, as I can't be sure they will follow up with cardiology. Or how about the abdominal pain of unclear etiology, as i have no clue that they will follow up for a recheck..... cause it may be an appy.

I give them the on call neurologist and it is there responsibility to follow up. I also tell them to come back if they have any issues.

We are not responsible for fixing outpt care issues.

I agree with the above, except I usually call the on-call Neurologist, then DOCUMENT that they said to send the patient home and follow-up in clinic.

 

[WilcoWorld]

I agree with the above, except I usually call the on-call Neurologist, then DOCUMENT that they said to send the patient home and follow-up in clinic.

That would be great if my usual conversation didn't go like this:

"Well, he'll need an MRI, an EEG, thyroid studies, RPR, B12 levels...you should just admit him to Medicine."

So, give me some time to read that NEJM article and get back to this issue (it might take some time, since I'm moving tomorrow, so bear with me).

Thanks for the input so far. As of yet it seems like there's considerable variabilty, and thus "Standard of care" is nebulous at best.

To EM2BE: Yes, age plays a role. If the patient is in the range of expected febrile seizure, and had a spiking fever at the time of onset, then I'll send them home after a negative work up (the extent of which is a WHOLE other discussion), and if the patient is old, then I have a lower threshold to admit (as with just about everything).

 

[elwademd]

Attached you'll find an article from the NEJM discussing management similar to your question stem. It discussing initial therapy and work-up, written from the neurology perspective. Sometimes find it interesting to see their standard of care, which influences ours.

Initial Management... French, et.al
NEJM 2008; 359:166-76

to be fair, the article is about epilepsy (2 seizures or more), not 1st seizure.

good article, though it is striking to think that nearly 2/3 of those with epliepsy will have an unknown cause.

 

[crewmaster1]

We have an "urgent new onset seizure clinic" that we can schedule patients into. We just go to registration and say we need an urgent f/u appt and they have one in the next one, at worst, two weeks. Get a bit of an ativan taper and off you go.

 

[GeneralVeers]

That would be great if my usual conversation didn't go like this:

"Well, he'll need an MRI, an EEG, thyroid studies, RPR, B12 levels...you should just admit him to Medicine."

So, give me some time to read that NEJM article and get back to this issue (it might take some time, since I'm moving tomorrow, so bear with me).

Thanks for the input so far. As of yet it seems like there's considerable variabilty, and thus "Standard of care" is nebulous at best.

I guess it depends upon the neurologist. The one I used to call in Texas was very reasonable about starting them on anti-seizure meds (like Keppra) and then following them up outpatient.

 

[emergentmd]

I have never had a neurologist where I work (Texas), that has ever asked me to admit or do any further work up for a new onset seizure.

Thus I have stopped calling and just given them a number to call as I have asked many neurologist and they always say just to send them.

 

[southerndoc]

I guess it depends upon the neurologist. The one I used to call in Texas was very reasonable about starting them on anti-seizure meds (like Keppra) and then following them up outpatient.

I've never started a first-time seizure on antiepileptic meds unless it's associated with a head injury. Our neurologists don't think it's necessary unless they have two seizures. They have good data to support not starting it.

9% of the population will have a seizure at some point in their life; only 1% of the population develops recurrent seizures requiring medication.

 

[WilcoWorld]

I've never started a first-time seizure on antiepileptic meds unless it's associated with a head injury. Our neurologists don't think it's necessary unless they have two seizures. They have good data to support not starting it.

9% of the population will have a seizure at some point in their life; only 1% of the population develops recurrent seizures requiring medication.

Yes, but of those who have a 1st seizure, about 20% go on to have another seizure within 2 years. (NEJM, 7/10/08, pg. 166) I don't mean that we should be starting anti-epileptic meds from the ED, but the numbers do look slightly different when your patient has pre-selected himself into this group.

 

[southerndoc]

Yes, but of those who have a 1st seizure, about 20% go on to have another seizure within 2 years. (NEJM, 7/10/08, pg. 166) I don't mean that we should be starting anti-epileptic meds from the ED, but the numbers do look slightly different when your patient has pre-selected himself into this group.

Those numbers are still too low to start anti-epileptics. The majority of patients will not develop a second seizure.

 

[emergentmd]

I never start a person on meds with the first seizure unless some odd reason exist. This is in accordance with most neurologist I talk to.

 

[dchristismi]

Timely...
Had my first new onset seizure case as an attending last night.

Of course, the guy was febrile, altered, and had just completed chemo for glioblastoma. Oh, and moved here yesterday. Yep, the truck was still unpacked sitting in their driveway.

I decided to admit him. Maybe it was rash, but you know, I'm being uber-conservative these days.

 

[WilcoWorld]

Febrile with recent chemo? I can't imagine anyone would fault you for admiting that patient...


Oh wait, you were being sarcastic. Damn the internet & it's lack of non-verbal cues!

 

[dchristismi]

Snort.

I actually thought about making some reference to me being a smart-ass, but figured that, like most of us, 80% of what I post is purely smart-assed. And that you (collectively) would pick up on it.

We need a sarcastic smilie. I went to look for one, and found:





I love it!
Of course, now I'm just ing