Suspected seizure: ED / AMAU (Guidelines)

• Clinical assessment according to ABCDE and manage in appropriate monitored area
• Exclude hypoglycaemia and treat if present
• If ongoing reduced conscious level: manage in appropriate area, involve senior and consider CT
• If significant head injury: follow ED / NICE guidance: ED Head Injury Guidance (NHS Highland intranet access required)
• If convulsive seizure lasting longer than 5 mins, or recurrent seizures without recovery in between: then treat according to: Prolonged seizure / status epilepticus in adults (Secondary Care) (Guidelines)

Main aims of assessment:

• Distinguish an epileptic or psychogenic non-epileptic seizure from syncope: See diagnostic flow chart below, and ED TLOC guidance (NHS Highland intranet access required)
• Identify whether the seizure is a symptom of an acute disorder, rather than the first presentation of epilepsy. See acute symptomatic seizures section.  
• The diagnosis is usually made by taking a careful history.
  You may be the only person to get a clear history and eyewitness account. By the time the patient is seen in the First Fit clinic the story may be less accurate or complete.
• All patients should have a physical examination, including neurological and cardiac examination.

Common causes of acute symptomatic seizures:

• Intoxication with or withdrawal from alcohol: Unplanned alcohol withdrawal (Guidelines)
• Recreational drugs such as cocaine or synthetic cannabis.
• Overdose of prescribed medication e.g. tricyclic antidepressants.
• CNS infection (meningitis, encephalitis): Consider in patients who are encephalopathic, have meningism or a fever.
  Note: simple febrile seizures DO NOT occur in adults.
• Metabolic abnormalities, especially hyponatraemia and hypoglycaemia.
• Acute intracranial pathology: Particularly head injury, intracranial bleed (or less commonly infarct),
  tumour.
• Eclampsia

Bloods:

• FBC, UEs, Mg, Ca, LFTs including GGT, CK, CRP, glucose or BM.
  Note: a high WCC is common after a convulsive seizure, and does not necessarily indicate infection.

ECG:

• ALL patients with loss of consciousness. Remember to note the QT interval

Neuroimaging:

CT head should be performed in the ED whenever an intracranial lesion is suspected:

• New focal neurological deficit or signs of raised intracranial pressure
• Persistent altered mental state
• Fever or other signs of meningitis / encephalitis
• Sudden onset or persistent headache
• Focal or partial onset before generalization
• Head injury
• History of malignancy
• Immunocompromise, including HIV infection
• Alcohol dependence (discuss with senior to avoid repeated scans in frequent attenders)
• Anticoagulation or bleeding diathesis
• Consider in patients unlikely to return for follow up

Urine pregnancy test:

• ALL women of childbearing age.

CXR and toxicology screening:

• ONLY if clinically indicated.

If suspicion of CNS infection:

• Treat empirically and consider LP.

• Consider onward referral for inpatient assessment. See below. 
• Patients who have fully recovered, with no neurological deficit and normal initial investigations, can be discharged.
• ALL patients should be given a copy of the First Fit Leaflet (NHS Highland intranet access required)
• Give driving, safety and first aid advice, and document this in the medical notes
• Refer patients who have had a first epileptic seizure to the First Fit Clinic, using the Suspected 1st Seizure Referral form (NHS Highland intranet access required).
• Patients with suspected NEAD or established epilepsy may be referred via the general neurology referral pathway. 

• ABCDE: Airway, breathing, circulation, disability, exposure
• BM: Blood glucose monitoring
• Ca: Calcium
• CK: Creatinine kinase
• CNS: Central nervous system
• CRP: C-reactive protein
• CT: Computed tomography
• CXR: Chest x-ray
• ECG: Echocardiogram
• ED: Emergency Department
• FBC: Full blood count
• GCS: Glasgow coma scale
• GGT: Gamma-glutamyl transferase
• HIV: Human immunodeficiency virus
• LFTs: Liver function tests
• LP: Lumbar puncture
• Mg: Magnesium
• NEAD: Non-epileptic attack disorder
• NEWS: National early warning score
• TLOC: Transient Loss of Consciousness
• U&Es: Urine and electrolytes
• WCC: While cell count