Symptoms and signs

Before

• Provoking factors include:
  • sleep deprivation
  • acute alcohol or substance intoxication
  • alcohol withdrawal
  • infection
• Prodromal symptoms of seizures often bizarre and hard for patients to describe

During

• Where possible, obtain eyewitness accounts
• Symptoms/signs that may be present:
• myoclonic jerking
• tonic-clonic movements
• tonic-clonic movements
• lateral tongue biting (biting tip of the tongue or the cheek is not suggestive of a generalised seizure)
• incontinence (not specific and can occur in any type of collapse in patient with full bladder)

After

• Generalised seizures are usually followed by a period of at least 10 min (often more), when patient truly confused (post-ictal state)
  • almost always have amnesia for this period
• Other symptoms (e.g. headache and aching limbs) are more suggestive of seizure than syncope

Examination

• Look for any injury sustained, including evidence of lateral tongue biting
• Full neurological examination
• Auscultation of heart for murmurs
• Stigmata of other conditions associated with seizures
  • e.g. chronic liver disease/alcoholism, café-au-lait spots suggesting neurofibromatosis

Investigations

• Blood glucose
• U&E
• Serum corrected calcium
• If known alcoholics/malnutrition, Mg
• FBC
• If alcoholism suspected, LFT
• ECG
• CT scan of head if:
• new focal neurological deficit
• persistent altered mental status
• fever or persistent headache
• recent head trauma
• history of cancer or HIV infection
• focal or partial onset seizure
• anticoagulation or bleeding diathesis
• history of stroke or TIA
• follow-up cannot be ensured e.g patients with alcohol/illicit drug use induced seizure

Differential diagnosis

• Several conditions can mimic an epileptic seizure

Functional (pseudo) seizure

• Detailed event description required
• Discuss with neurology registrar

Vasovagal episode

• Loss of consciousness, usually provoked (e.g. pain)
• Presyncopal symptoms include:
  • dizziness
  • nausea
  • clamminess
  • 'feeling faint'
• Rapid recovery of awareness

Postural hypotension

• Within 3 min of standing, systolic BP falls to <90 mmHg or falls by >20 mmHg

Cardiac syncope

• Causes include:
  • ischaemia
  • Wolff-Parkinson-White (WPW) syndrome
  • long-QT syndrome
  • bradycardia
  • tachycardia
  • structural heart disease (e.g. aortic stenosis)
• Syncope can occur with or without cardiac symptoms
• A Stokes-Adams attack is classically associated with pallor followed on recovery by flushing

Carotid sinus hypersensitivity

• Rare
• Usually in an elderly patient
• Precipitated by head turning or pressure on neck (e.g. shaving)

Hyperventilation

• Anxiety
• Paraesthesia of perioral region or extremities
• Palpitations
• Chest pain

Electrolyte abnormalities

• Hypoglycaemia
• Hyponatraemia
• Hypo- or hypercalcaemia
• Hypomagnesaemia
• Uraemia

Known epilepsy

• Advise patient to contact their epilepsy nurse after discharge

Review triggers

• Poor compliance with medication
• Intercurrent illness or infection
• Alcohol or drug ingestion
• Part of normal seizure pattern

First adult generalised seizure

Medication

• If seizure resolved spontaneously, none
  • inappropriate use of diazepam can result in unnecessary admission and cause respiratory depression
• Seek advice from neurology SpR or consultant before starting anticonvulsant therapy

Results of tests

• If hypoglycaemia, address underlying cause, then reassess. See Hypoglycaemia guideline
• If focal neurological abnormalities found or CT scan abnormal, contact on-call neurology SpR

Admission criteria

• Patient remains drowsy or comatose
• Neurological examination abnormal
• Investigation results abnormal
• Patient at high risk of further seizures (e.g. alcohol withdrawal)
• Patient cannot be supervised by a responsible adult 

Known epilepsy

• Continue with present epilepsy care

First seizure

• Refer for further assessment at neurology outpatient 'First fit' clinic

Advice to patients

• Advise patient to return to A&E if a further episode occurs
• Advise patient that they have been referred to First Fit Clinic

Driving and work

• Advise patient to stop driving and to inform DVLA
  • following a first single epileptic seizure, Group 1 entitlement drivers (motor cars and motorcycles) may restart driving after 6 months if agreed by appropriate specialist and no abnormality found (e.g. EEG and brain scan normal)
  • if any pathology exists, refrain from driving for 1 yr before subsequent medical review
• Patients should inform their employer that they have had a seizure in order to fulfill the requirements of Health and Safety at Work legislation
• Record this advice explicitly on casualty card