EM · Seizures and first fit

Seizures and the first fit

Also known as First seizure · New-onset seizure · First fit · Provoked seizure · Unprovoked seizure

The first seizure in the emergency department — the operational definition (an epileptic seizure, ILAE 2014 definition of epilepsy: two unprovoked seizures over 24 hours apart, or one unprovoked seizure with at least 60 per cent recurrence risk over 10 years), the provoked versus unprovoked distinction that drives every downstream decision, the workup (capillary glucose, sodium, calcium, magnesium, toxicology, ECG, beta-hCG, non-contrast CT, lumbar puncture if fever, EEG within 24 to 72 hours, outpatient MRI), the management (ABCDE, a benzodiazepine only if ongoing or recurrent, admission if first seizure with abnormal neurology or recurrent in the department, antiepileptic drug initiation based on recurrence risk with levetiracetam preferred and valproate avoided in women of childbearing potential), the recurrence prognosis (about a third recur at two years, higher with an abnormal EEG, an imaging lesion, a nocturnal seizure or a prior neurological insult), the differential (syncope, psychogenic non-epileptic seizure, hypoglycaemia, TIA, Todd paresis), and the driving restrictions (Austroads: 6 months off a private licence after a first unprovoked seizure, 12 months for established epilepsy, 5 to 10 years commercial). ACEM-primary, globally tagged.