REBEL Core Cast 36.0 – Seizures

Take Home Points

  • When approaching the patient with uspected seizure, focus on questions that matter in determining if the event was a seizure or not
  • Extensive lab work after a first time seizure is not necessary in patients who are back to baseline.  Focus on serum glucose, determining pregnancy/postpartum status, and in patients who continue to seize, check that sodium!
  • Get a CT of the Head on
    • First-time seizure patients
    • High-risk groups (alcoholics, immunocompromised, infants < 6 months of age)
    • Those with an abnormal neuro exam
    • Those presenting with focal seizures
  • Psychogenic non-epileptic seizures are difficulty to distinguish from true epilepsy and there is significant overlap between the two conditions.  Take all seizure activity seriously.
  • Give clear discharge instructions to your first-time seizure patients and close the loop on close neurology follow-up.

REBEL Core Cast 36.0 – Seizures


  • Definition – an episode of disturbed cerebral functions characterized by excessive and synchronous discharges by cortical neurons
  • 2 types
    • Provoked – attributable to an apparent cause (electrolyte disturbance, drug/EtOH withdrawal, eclampsia)
    • Unprovoked – no identifiable cause
  • Convulsions – the motor manifestations of the abnormal brain activity
  • No single ED test or information from the history is 100% diagnostic of a seizure

Seizure mimics:

  • Syncope (20% will be convulsive syncope)
  • Convulsive concussion
  • Posturing
  • Psychogenic non-epileptic spells (PNES)
  • certain TIAs
  • other neurologic movement disorders

Characteristics that are non-diagnostic of seizure:

  • urinary incontinence
  • lightheadedness prior to the event
  • paresthesias
  • activity prior to the event
  • headache after
  • sustaining an injury

Characteristics that are helpful (make seizure more likely)

  • lateral tongue biting
  • eyes open during the episode
  • post-event confusion
  • a forward or unilateral gaze during the episode

First-time seizure ED work-up:

  • POC glucose!
    • Most common cause of provoked seizure
  • ECG (to rule out dangerous mimics)
  • FULL vital signs!
    • temperature, blood pressure, oxygen saturation
  • Pregnancy/Postpartum status
    • up to 6 weeks postpartum at risk for eclampsia
  • Sodium level
    • especially if seizure is not resolved
  • CT of the head
    • may change management in the ED up to 17% of the time
  • Let the patient’s medical, social, and medication history dictate any further workup

High-risk groups in which to always get a CTH:

  • Those not back to baseline
  • Chronic alcohol use
  • Immunocompromised
  • Infants < 6 months of age
  • Those with an abnormal neuro exam
  • Those with focal seizures
  • Recent neurosurgical intervention/instrumentation

Psychogenic Non-Epileptic Seizures (PNES)

  • Involuntary episodes NOT associated with abnormal cerebral discharges
  • Often associated with a history of PTSD, abuse
  • Triggering event is not usually readily identifiable
  • Between 5-60% of patients diagnosed with PNES will ALSO have a concurrent diagnosis of epilepsy
  • PNES does not equal malingering

Features of PNES:

  • long duration
  • gradual onset
  • asynchronous movements
  • closed eyes
  • pelvic thrusting, leg bicycling
  • moaning or talking through episode
  • side to side head & body movements
  • ictal crying
  • absence of postictal period
  • postictal stertorous breathing

Disposition for first-time seizures:

  • If back to baseline, relevant labs and CTH normal, patient can be discharged
  • Prompt follow-up with Neurology for EEG should be available
    • sensitivity of the EEG declines the further in time from the episode
  • AED prescription/loading is NOT necessary in patients with unprovoked first-time seizures
    • consider (in conjunction with Neurology colleagues) starting an AED in patients at higher risk of recurrent seizure
      • prior stroke or TBI
      • significant neuro-imaging abnormality
      • nocturnal seizure

Discharge instructions:

  • No bathing or swimming alone
  • No bathing children alone
  • No driving until cleared by a neurologist
  • Local/state laws differ across the country, but realize that they many require you as the physician to report seizures to the DMV
  • Prompt follow-up with a neurologist for EEG

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 36.0 – Seizures", REBEL EM blog, July 8, 2020. Available at:
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author

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