Management of Known Seizure Disorders

Initial Assessment and Stabilization

The American College of Emergency Physicians recommends that patients with known seizure disorders who have returned to their clinical baseline in the ED do not require routine admission 1
The American Academy of Neurology suggests timing the seizure duration, as ongoing seizure activity exceeding 5 minutes or multiple seizures without return to baseline defines status epilepticus requiring immediate intervention 2
Patients who have returned to their neurological baseline require less aggressive workup than those with persistent altered mental status, according to the American College of Emergency Physicians 1, 3

The American Academy of Neurology recommends checking serum glucose and sodium, as these are the only laboratory abnormalities that consistently alter acute management 3
The American College of Emergency Physicians suggests obtaining antiepileptic drug (AED) levels if the patient is on phenytoin, valproate, carbamazepine, or phenobarbital to assess subtherapeutic levels as a potential cause 4
Consider pregnancy testing in women of childbearing age, as this significantly impacts medication choices, according to the American College of Obstetricians and Gynecologists 3

The American College of Emergency Physicians recommends emergency CT head without contrast only when high-risk features are present, such as recent head trauma, persistent altered mental status, new focal neurological deficits, fever suggesting CNS infection, history of cancer or immunocompromised state, anticoagulation use, or age >40 years with new partial-onset seizure pattern 1, 2, 3, 6

The American Academy of Neurology recommends administering benzodiazepines immediately for any seizure lasting >5 minutes or recurrent seizures without return to baseline 2, 6
The American College of Emergency Physicians suggests administering an additional antiepileptic medication, such as valproate, fosphenytoin, or levetiracetam, if seizures persist after optimal benzodiazepine administration 4, 6, 7

The American College of Emergency Physicians recommends discharging patients who have returned to clinical baseline, have a normal neurological examination, no persistent altered mental status, no abnormal investigation results requiring inpatient management, and reliable follow-up arrangements established 1, 3
Consider admission for patients with persistent abnormal neurological examination, failure to return to baseline within several hours, abnormal investigation results requiring inpatient management, status epilepticus requiring ongoing treatment, or concern for underlying acute process (CNS infection, hemorrhage, stroke) 1, 3

The American Academy of Neurology reports an overall 24-hour recurrence rate of 19% in all seizure patients, with a mean time to first recurrence of 121 minutes (median 90 minutes) and 85% occurring within 6 hours 3, 6
Non-alcoholic patients with known epilepsy have a lower early recurrence rate of 9.4% 3