Please help a poor pcp

[scharnhorst]

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I'm seeing a few new adult seizure patients ,aafp and uptodate both recommend consulting neurology first before starting AED but if they cannot get in for 3 months and are having repeated seizures and never been on AED I doubt we can wait that long.In the past I have used Keppra and Dilantin as the 1st line AED for GTC seizures ( based on history and their intital ER report) with mixed results , does anyone have any other suggestions ?
seizures are generalized tonic clonic based on description but no EEG has been done as these pts cannot get into neurology and were not admitted inpatient

thanks in advance

 

[LuccaDO]

Consider sending to ED for urgent evaluation and to expedite workup if the wait is that long. Needs a good exam by a neurologist, imaging and EEG and if further concern an LP. Does not need to be admitted.

I am sure you are desperate and vouching for your patient right now, but I do not think it appropriate to seek consultation from this forum on an AED you will be placing someone on to temper their seizures. Good luck.

 

[Thama]

Agree with above - if your local neurologist doesn't have urgent appointments for new onset seizure patients, then they'll need to be sent to ED for urgent evaluation, preferably to a hospital with neurologists on staff. In general Keppra is a good 1st line agent and usually safe in the absence of psychiatric disease (would not use Dilantin 1st line in most cases), but there are a lot of potentially dangerous causes of new onset seizure in an adult that should be evaluated by a neurologist in a more urgent fashion than just giving an appointment for 3 months later.

 

[deathmerchant]

Disclaimer: This is not professional advice --
An adult with new onset seizures = urgent evaluation by neurology.
Sending to ER is probably best. Obtaining an MRI w contrast, as soon as possible and not to delay starting an appropriate AED(if needed) is paramount as this is a life threatening conditioning for the patient and other people.

 

[scharnhorst]

THANK YOU ALL !

 

[oopsy]

Just for your own reference, the MESS trial is how we risk stratify these folks:
Prediction of risk of seizure recurrence after a single seizure and early epilepsy: further results from the MESS trial. - PubMed - NCBI

Essentially, you're asking the question of who is likely to recur, and as such, merit therapy. If they're having multiple events (no within the same 24hr-epoch), EEG abnormality, or MRI abnormality, they basically automatically get AEDs. It is also not unreasonable to put them on an AED until a neurologist sorts it out.

Finally, please be sure the ED you're sending them to has neurology coverage. I can't tell you how many times I've seen patients sent in for a 1st time seizure eval, shipped out by a random ED without neurology, all the way out to see us at a referral center, and then I send them home from the ED b/c it's a first time seizure with no high risk features.