Written by Jonathan Brewer
It is beneficial for emergency providers to have an algorithm for abortive therapy for epileptic seizures in the Emergency Department (ED). However, diagnosing epilepsy and starting anti-epileptic drugs (AEDs) can be life-altering with potential long-term effects, so this decision needs to be made after further testing and possible neurology consultation or referral.
Why does this matter?
We commonly see seizures in the emergency department. Whether this be the 1st or 20th episode, and whether it be a transient event or status epilepticus, we need to be prepared to manage seizures in the ED. The initial resuscitation should focus on the suppression of seizure activity and identifying potential life-threatening etiologies, but what happens after the seizure stops?
The seizure stopped. Now what?
This NEJM review article predominantly focuses on the recognition of various presentations of seizures and when to start anti-epileptic drug therapy. This article does not focus on ED-specific management for a patient who is actively seizing, but instead focuses more on further testing needed to make the diagnosis of epilepsy and how to proceed once the diagnosis is made.
Confirming the diagnosis of first-time epileptic seizure can be challenging, and there are several seizure mimics such as syncope, psychogenic nonepileptic seizure, and panic attack. A detailed history, exam, and eyewitness accounts are vital to make the clinical diagnosis of seizure. If this is a first-time event, the episode should be followed by head imaging, basic blood tests including electrolytes and glucose, and a 12-lead ECG. The article suggests that most adults with first time seizure, especially focal-onset seizure, should have urgent MRI brain to identify more subtle underlying structural causes of seizure that may be missed on CT. In addition, urgent interictal EEG should be attempted as EEG performed soon after a first seizure identifies more epileptiform abnormalities than a later EEG. This highlights the importance of urgent neurology follow up for patients seen in the ED with first time seizure.
Once the risk of further spontaneous seizures has been judged to exceed 60% over the next 10 years, AEDs are indicated. It is important to remember that these are usually lifelong medications that have various side-effects ranging from drowsiness to teratogenicity to Stevens-Johnson Syndrome. The diagnosis of epilepsy and initiation of AEDs is a major clinical decision and a life changing event for your patient and should usually be done in consultation with our Neurology colleagues. Finally, as with many diagnoses, remember to discuss various lifestyle changes with your patient to prevent future seizure episodes (i.e., decreased alcohol intake and getting a full night’s rest) as well as the risks of having a seizure while driving or performing other high-risk activities.
Edited and Peer Reviewed by Sam Parnell
Initial Management of Seizure in Adults. N Engl J Med. 2021 Jul 15;385(3):251-263. doi: 10.1056/NEJMcp2024526.