First seizure — assessment, investigation and disposition

Assessment (ABCDE + glucose + witness history). Airway — recovery position, suction, oxygen. Breathing — saturation, capnography. Circulation — IV access, blood pressure. Disability — check the capillary glucose at once (the most important bedside test; treat with 50 mL of 50 per cent dextrose IV and thiamine 100 mg if low or alcoholic). Examine the pupils, document the GCS, the temperature, and a focused neurological examination for a focal deficit or a Todd paresis. Take a witness history (the most valuable single piece of information): the onset, the duration, the motor pattern, the recovery, and the provoking context (alcohol, sleep deprivation, drugs, recent illness, head injury). Confirm this is a first seizure and not a recurrence, and screen for a known cause (family history, prior head injury, febrile seizures in childhood). Establish whether the seizure has fully stopped — a seizure that does not stop at 5 minutes is status epilepticus and runs the benzodiazepine ladder (lorazepam 4 mg IV, repeated once).

Investigations. In the stopped, stable first seizure, answer four questions: is there a reversible metabolic or toxic cause, a structural intracranial cause, an infective cause, or a cardiac cause masquerading as a seizure? Send bloods: sodium, calcium, magnesium, glucose, urea and creatinine, liver function; a beta-hCG if applicable; a toxicology and ethanol screen if toxin or withdrawal is suspected. ECG on every patient — look for a long QT, a Brugada pattern, a conduction block, ischaemia or pre-excitation (a cardiac arrhythmia masquerading as a seizure must not be missed). Non-contrast CT brain is performed here because he is not yet back to baseline (drowsy and confused) — it excludes a haemorrhage, a mass or a stroke as the cause. Lumbar puncture only if fever or meningism after the CT. EEG within 24 to 72 hours (outpatient, or inpatient if he fails to wake — suspected non-convulsive status), and an outpatient MRI brain as the gold-standard structural study arranged by neurology.^[2]

Disposition — admit. Admit this patient: he has not yet returned to baseline (he is drowsy and confused), which is an admission criterion.^[2] He also needs a CT now and observation until recovered. If the CT and the bloods are normal and he returns to baseline, discharge is possible with an outpatient EEG within 24 to 72 hours, an outpatient MRI, a neurology referral, written safety advice, and the driving restriction explained and documented.

Antiepileptic drug and counselling. A first unprovoked seizure does not automatically require an antiepileptic drug tonight — the MESS trial and the Cochrane review show immediate treatment delays but does not prevent long-term recurrence, so the decision is made with the neurologist and the informed patient, weighing the recurrence risk (high if an epileptiform EEG, a structural lesion, a nocturnal seizure or a prior neurological insult — about a third recur at one year overall).^[1][2][3] Driving: under Austroads Assessing Fitness to Drive he must not drive a private licence for a minimum of 6 months after a first unprovoked seizure, he has a legal duty to notify the licensing authority, and I document the advice in writing. Safety advice: avoid baths unaccompanied, heights, swimming alone, and excess alcohol; return if recurrent.