Rural Pearl- First time seizure

You are back for you solo overnight shift at Rural General Hospital.  At 2 am a new patient comes in with his fiance.  He is a 25 year old male and the fiance says the patient had a “shaking episodes” an hour prior to coming to the hospital.  She describes the event as a generalized, tonic clonic seizure.  The patient has no seizure history and had no pre-seizure symptoms, no changes in medication, no infectious symptoms, and is not a daily drinker.  The patient is now back to baseline, AOx4 and has a completely normal neurological exam.  It is late at night and he wants to go home.  You try calling the neurologist and your regional hospital for recommendations but they are unhelpful.  What do you do next?


What is the evidenced based management of patients with unprovoked first time seizures?

The answer comes from EMpractice “Current Guidelines for Management of Seizures in the Emergency Department” courtesy of our own Reuben Strayer.  


What labs need to be ordered on this patient?

There are two level B recommendations that include serum glucose/serum sodium and a urine pregnancy test in women of childbearing age.  


Does an LP need to be performed?

Again there is a level B recommendation to perform LPs after head CTs on all immunocompromised patients.


Does our patient need a head CT?

A Level B recommendation states that neuroimaging should be performed when “feasible” which in our setting is almost always.  


What is this patient’s disposition?

Patients with normal neurological examination can be discharged with outpatient follow up (leve C).


Do they need to be started on antiepileptic drugs (AEDs)?

Also a level C recommendation that patients who have returned to baseline and have no focal deficits can be sent home without medication.  According to recommendations by the American Epilepsy Society with the American Academy of Neurology, AEDs may reduce the risk of a second seizure in the first 2 years (Class B) but also come with significant risk of adverse events (7 to 21% Risk).


Do you have to report this seizure to the state?

According to the following states have mandatory reporting: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania.  If you are in a state without mandatory reporting you should still advise the patient to not drive until they have followed up with their neurologist.  



Strayer, R. et al “Current Guidelines for Management of Seizures in the Emergency Department”. EBmedicine, January 2010 Volume 2, Number 1.  


“Management of an Unprovoked First Seizure in Adults”

June 2024