How Do We Evaluate, Treat, and Disposition New
Onset Seizure Patients?
KHALID MBAYA (M.D)
SUPERNUMERARY REGISTRAR
JOINT DIVISION OF EMERGENCY
MEDICINE UNIVERSITIES OF
STELLENBOSCH AND CAPETOWN
• A 25 years old female, known RVD +Ve
not yet on ARVs, with CD4 counts of 95, is
reffered from MDHS to GFJ on 24/01/2010
.Reason for referral is to do CT scan of
brain because the patient had an episode
of seizure followed with confusion few
hours ago. The patient was given a stat
dose of Ceftriaxon 2gm at MDHS before
transfer to GFJ.
Questions
• Why the patient was given Ceftriaxon 2gm?
• What do you think was the diagnosis of this
patient in the mind of referring doctor?
• What reasons could probably made him to
request CT of brain?
-Afraiding of herniation of intracranial mass if he
does LP?
-Formality? Standard of care?
-To confirm diagnosis?
• The patient arrived at GFJ hospital on 25/01/2010 at 00h30.
Vitals: B.P 108/75 mmhg, Pulse 88/min
Temperature 35.5°C, Hb 8.4
Vx 7.7
Collateral from the mother: The patient had a fit in the morning and was
unable to to talk for about 5minutes.she peed on herself.After that
episode the patient remained confused untill they arrived at the day
hospital. The patient is not known to be epileptic and was scheduled
to start ARV clinic next day.
On examination: The patient looks calm, oriented to TPP. Normal
physical and systemic findings.
Blood was drawn for EUC and FBC, and results was: Na 135, K 4.6,
WCC 7.6, Hb 10.9, Platelets 561.
Due to normal neurological findings, LP was done and 10mm3 of clear
fluid under moderate pressure drawn and sent to the lab. Results
were obtained just before the morning ward rounds. Poly 0, lymph 0,
Eryth 72, gluc 3.6, indian ink –ve, culter pending.
• 24/01/2010 at 0800 W/R with int.medicine
consultant Dr.Nyo:
-Why did you do LP? That is very
dangerous
-Since the LP results are normal, and
patient looks fine, plans are as follow:
1.Descharge the patient to come back the
next day for CT brain.
2.Start anti epileptic, Epilim 500mg b.d.
The patient was then descharged early in
the morning.
• The same day after being discharged, at 16h00
the patient is brought back by her mother. She
reports that the patient has become confused
again, she is agitated, over talkative and talks
abusive languages. She even beats her children
unnecessarily. No fits were observed.
• On arrival the patient started moving around the
beds talking to each patient and some time
intimidating them.
• Vital signs were taken and found to be normal.
• On examination, the patient was anxious,
increased pressure speech, over talkative but
oriented to TPP. Physical and systemic findings
were normal.
• The patient was given Diazepam 10mg iv and
slept the whole night quietly.
• 25/01/2010 08h00, Ward round with Dr.Aboo.
-The patient looks calm, normal vital findings.
- Who did the LP? And why? Somebody must have told
him. These are Americans books confusing people.
- This patient has toxoplasmosis, why not on bactrim?
Plan: Do CT scan now.
- Forms filled and signed for requesting CT of brain.
- Results: CT Machine is not working. Patient booked for
CTB on 05/02/2010.
The patient was discharged with the following treatment:
- Bactrim 4tabs b.d x 1/12
- Epilim 300mg b.d x 1/12
- Panado 1gm t.d.s x 1/52
- To start ARVs at local hospital
Questions
• Bearing in mind the bureaucrats and difficultness of
getting CT scan done in our hospitals
-what could have been done to this patient if LP had not
been done?
1.Treat her as Menengitis (Bacteria?Viral? Criptococcus?)
until CTB done to confirm toxoplasmosis?
2.Treat her as Toxoplasmosis until CTB done to exclude it,
then do LP to find for menengitis?
3.Treat her as Menengitis and Toxoplasmosis until CTB
then LP done to exclude either.
Key Clinical Questions
• What are the key components of the history and physical
in a patient with a first time seizure?
• What laboratory tests are indicated in this patient in the
ED?
• Does this patient need a neuroimaging study in the ED?
• Which patients with new onset seizures should be
started on AEDs in the ED?
• Which patients with new onset seizures need to be
admitted to the hospital?
• Is it safe to LP before CT brain?
Recommendations
– Class A: None specified.
– Class B:
1. Perform a lumbar puncture either in the emergency department or
after admission in patients with a first time seizure with HIV
disease following a head CT.
2. Determine a serum glucose and electrolytes on patients with first
time seizure with no co-morbidities who have returned to their
baseline.
3. Obtain a pregnancy test if a woman is of child bearing age.
4. Perform a Neuroimaging of the brain in the emergency department
on patients with a first time seizure. If Neuroimaging of the brain is
not available in the emergency department, discuss the risk of
recurrence with the patient and the patient’s primary physician and
either admit the patient to the hospital or make arrangement for an
outpatient evaluation.
Recommendations
• Class C:
1. Patients with a first time seizure who have a normal
neuroimaging of the brain, normal serum glucose and sodium,
and normal neurologic examination can be discharged from the
ED with outpatient follow-up.
2. Patients with a first time seizure who have a normal neurologic
exam, normal neuroimaging of the brain, normal serum glucose
and sodium, and no co-morbidities do not need to be started on
an antiepileptic drug (AED) in the ED.
New Onset Seizures
• 5% - 6% of the population will have at least one
seizure during their lifetime
• Diagnostic work-up in the ED depends on the
clinical exam and co-morbidities
• Etiologies of first time adult seizures (age group
dependent and co-morbidity dependent (eg HIV):
– Chronic alcohol consumption (30-60 year
olds)
– Cerebral vascular insults (>60 year old)
What laboratory tests are indicated in the ED
evaluation of a patient with a new onset sz?
• ACEP Clinical Policy. Ann Emerg Med
1997; 29:706
– Patients with a normal exam and no comorbities: Glucose level, electrolytes,
and pregnancy test
– Consider a drug of abuse screen
– Patients with co-morbidities require
more extensive testing
– CPK and prolactin levels are of limited
value in the ED
Lumbar Puncture
• A LP in the ED is not indicated if the patient:
– Is not immunocompromised
– Has returned to baseline
– Has no fever or meningeal signs
• There are no cases reportedof meningitis
presenting as a simple tonic clonic seizure
• Postictal pleocytosis (>5 polys in the CSF) has
been reported in 2 - 18% of patients who have
had a GTCS
Neuroimaging: Head CT and MR
• Three per cent to 41% of patients with a
first time seizure have an abnormal
head CT
• Imaging is dependent on the urgency of
the evaluation and patient stability
• Literature interpretation depends on
outcome measure used
Neuroimaging in New Onset
Seizures
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ACEP, AAN, AANS, ASNR. Practice Parameter: ED neuroimaging in the seizure
pt. Ann Emerg Med 1996; 27:114-118. Evidence based practice guideline
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Emergent CT for patients with altered mental status, trauma, focal exam,
immunocompromise, fever, co-morbitidity
Patients who are alert with a nonfocal exam can have an outpatient study
Focal abnormalities on CT are reported in up to 40% of patients with new onset
seizures; up to 20% have non-focal exams
MRI is better than CT in detecting subtle lesions (e.g., hippocampal sclerosis)
but impact on care is controversial
GF JOOSTE HOSPITAL CLINICAL GUIDELINES 2010: pg 46 APROACH
TO FISRST SEIZURE:
-Hiv+ve or suspected, awake, no focal signs, no papilloedema, no meningism=
CT scan within 1 week, LP if no contraindication.
pg 50: Urgent scan (within 48hrs)= First time seizure in HIV positive patients if
a lumbar puncture is normal (L.P’s should only done if no focal signs)
Treatment and Disposition
• Decision to admit or to initiate AED treatment
depends on the risk of recurrence
– Etiology and EEG are the strongest predictors
– Recurrence risk in the first 24 hours is up to
23% in patients with a focal lesion and 9% in
patients with a first time seizure of
undetermined etiology (Tardy: study has many flaws)
• No prospective studies exist; no outcome
studies
Treatment and Disposition
• Management must be coordinated with
a neurologist or primary care provider
• Patients needing immediate AED
treatment can be loaded with
intravenous phenytoin or valproic acid
• Decision to admit depends on the
assessed risk of recurrence, patient
compliance and social circumstance
Areas in need of future research
• Prospective study investigating laboratory
testing in patients with new onset seizures
• Prospective study of neuroimaging in new
onset seizures and impact on outcome
• Prospective study on seizure recurrance
within 72 hours in patients with new onset
seizure and no etiology identified in the ED
• Prospective study on risk stratification in the
ED and implementation of AED therapy
Definitions
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Level A recommendations. Generally accepted principles
for patient management that reflect a high degree of clinical
certainty (ie, based on “strength of evidence Class I” or
overwhelming evidence from “strength of evidence Class
II” studies that directly address all the issues).
Level B recommendations. Recommendations for patient
management that may identify a particular strategy or
range of management strategies that reflect moderate clinical
certainty (ie, based on “strength of evidence Class II”
studies that directly address the issue, decision analysis
that directly addresses the issue, or strong consensus of
“strength of evidence Class III” studies).
Level C recommendations. Other strategies for patient
management based on preliminary, inconclusive, or conflicting
evidence, or, in the absence of any published literature,
based on panel consensus.
Related articles or researches
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1. DeLorenzo R, Hauser W, Towne A, et al. A prospective, population-based epidemiologic study of
status epilepticus in Richmond, Virginia. Neurology 1996; 46:1029-1035. This is an important prospective
study that used a strict definition of status epilepticus involving 204 events. The authors report a projected
annual incidence of status epilepticus of 50 per 100,000 population, with an overall mortality of 22%; 3% for
children and 26% for
adults. According to the study, over one half of patients presenting to the ED in status epilepticus had no prior
seizure history. Mortality in patients with status epilepticus is linked to the duration of the seizures and the
underlying etiology
2. American College of Emergency Physicians. Clinical policy for the initial approach to patients
presenting with a chief complaint of seizure who are not in status epilepticus.
Ann Emerg Med 1997; 29:706-724.
This clinical policy is currently under revision. In essence, it is a formal consensus document that provides
general guidelines for approaching the patient who has had a seizure. The policy recommends that patients
with a first time seizure have, at a minimum, a set of electrolytes, a glucose level, and a pregnancy test if a
female of child-bearing age. Therapeutics are not addressed.
3. Turnbull T, Hoek T, Howes D, Eisner D. Utility of laboratory studies in the emergency department
patient with a new onset seizure. Ann Emerg Med 1990; 19:373-377.
This is a prospective study of 136 patients with new onset seizures seen over a four-year period; it is not clear
if these were consecutive patients (though doubtful thus introducing selection bias into the study). All patients
had an evaluation of electrolytes, BUN, Cr, CBC, glucose, calcium, and magnesium. 11 cases of laboratory
abnormalities were discovered, only two of which (patients with hypoglycemia) were not suspected. The
authors conclude that, with the exception of serum glucose, serum analyses are of low yield in patients with
new onset seizures who have normal physical exams and no co-morbidities.
4. Pesola G, Westfal R. New onset generalized seizures in patients with AIDS presenting to an
emergency department. Acad Emerg Med. 1998; 5:905-911.
This is a retrospective review of 26 AIDS patients with new onset seizures which were compared to 120 nonHIV patients. Four of the HIV patients were found to have treatable lesions that were not suggested by clinical
findings. This study supports the need for a CT and a LP in HIV patients with new onset seizures.
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5. Tardy B, Lafond P, Convers P. Adult first generalized seizure: etiology, biological
tests,
EEG, CT scan, in an ED. Amer J Emerg Med. 1995; 13:1-5.
This is the only study that specifically looks at seizure recurrence within 24 hours of
presentation. It suffers from its retrospective design with probable selection bias. Of 247
patients, alcohol and acute stroke were the most common etiologies identified. 5 patients were
hypoglycemic, 4 were hyponatremic, 3 had calcium or sodium abnormalities. 85 patients had a
focul lesion on head CT; 32% had an EEG with a focal abnormality. Seizure recurrence was
19% in the first 24 hours; when alcohol and focal lesions were excluded, the rate dropped to
9%. Unfortunately, a complete data set is not provided to allow for an of predictors that might
enable the clinican to risk stratify patients.
6. Henneman P, DeRoos F, Lewis R. Determining the need for admission in patients with
new-onset seizures. Ann Emerg Med 1994; 24:1108-1114.
This is a retrospective review of 333 adult patients with new onset seizures. The authors
conclude that patients needing admission can be predicted by a standardized medical
evaluation in the ED though unfortunately the retrospective study design did not allow for a
standardized evaluation to have been performed. A complete data set on patients is not
provided making it difficult to support some of the conclusions made by the authors.
7. American College of Emergency Physicians, American Academy of Neurology,
American Association of Neurological Surgeons, American Society of Neuroradiology.
Practice Parameter: Neuroimaging in the emergency patient presenting with seizure
(Summary Statement). Ann Emerg Med 1996; 27:114-118.
This is an important practice guideline that all emergency physicians should be familiar with.
The guideline was a joint collaboration between ACEP and the AAN and the AANR. An
evidence-based approach was taken to formulate recommendations. The three societies jointly
recommended that a neuroimaging study could be obtained as an outpatient if the patient the
neurologic exam was normal and no predisposing co-morbidites, eg malignancy, are identified.
COMPUTED TOMOGRAPHY OF THE HEAD BEFORE LUMBAR
PUNCTURE IN ADULTS WITH SUSPECTED MENINGITIS.
R0DRIG0 HASBUN, M.D., JAMES ABRAHAMS, M.D., JAMES JEKEL, M.D.,
AND VINCENT J. QUAGLIARELLO, M.D
• Background: In adults with suspected meningitis
clinicians routinely order computed tomography
(CT) of the head before performing a lumbar
puncture.
• Methods :We prospectively studied 301 adults
with suspected meningitis to determine whether
clinical characteristics that were present before
CT of the head was performed could be used to
identify patients who were unlikely to have
abnormalities on CT. The Modified National
Institutes of Health Stroke Scale was used to
identify neurologic abnormalities.
Results
• Of the 301 patients with suspected meningitis, 235 (78 percent)
underwent CT of the head before undergoing lumbar puncture. In 56
of the 235 patients (24 percent), the results of CT were abnormal; 11
patients (5 percent) had evidence of a mass effect. The clinical
features at base line that were associated with an abnormal finding
on CT of the head were an age of at least 60 years,
immunocompromise, a history of central nervous system disease,
and a history of seizure within one week before presentation, as well
as the following neurologic abnormalities: an abnormal level of
consciousness, an inability to answer two consecutive questions
correctly or to follow two consecutive commands, gaze palsy,
abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal
language (e.g., aphasia). None of these features were present at
base line in 96 of the 235 patients who underwent CT scanning of
the head (41 percent). The CT scan was normal in 93 of these 96
patients, yielding a negative predictive value of 97 percent. Of the
three misclassified patients, only one had a mild mass effect on CT,
and all three subsequently underwent lumbar puncture, with no
evidence of brain herniation one week later.
Conclusions
• In adults with suspected meningitis,
clinical features can be used to identify
those who are unlikely to have abnormal
findings on CT of the head. (N EngI J Med
2001;345:1727-33.)
Questions
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