Initial Emergency Department Workup for Patients with Seizures

Laboratory Testing

The American College of Emergency Physicians recommends determining serum glucose and sodium levels for all patients with seizures, as these are the most frequent abnormalities identified and can directly cause seizures 1, 2
Obtain a pregnancy test for all women of childbearing age, as pregnancy status affects testing, disposition, and medication decisions 1, 2
Routine testing for calcium, magnesium, or phosphate levels is not supported by evidence in otherwise healthy patients 3
Consider checking urine for blood to detect evidence of rhabdomyolysis, which can be a complication of seizures 4

When feasible, perform neuroimaging of the brain in the ED for patients with a first-time seizure 1, 5
Head CT should be performed emergently when an acute intracranial process is suspected, particularly in patients with a history of acute head trauma, malignancy, immunocompromised status, fever, persistent headache, history of anticoagulation, new focal neurologic examination, age older than 40 years, or focal onset before generalization 1, 5
MRI is the preferred imaging modality for non-emergent situations 2

Patients with a first unprovoked seizure who have returned to their clinical baseline in the ED may not require admission 2
Consider admission if any of the following are present: persistent abnormal neurologic examination, abnormal investigation results, or patient has not returned to baseline 2
The mean time to first seizure recurrence is 121 minutes (median 90 minutes) with more than 85% of early seizures recurring within 6 hours 2, 5
Non-alcoholic patients with new-onset seizures have the lowest early seizure recurrence rate (9.4%) 2

For patients with status epilepticus (seizure lasting >5 minutes or multiple seizures without return to baseline), prompt treatment with benzodiazepines is essential 6