Last reviewed: March 2026
Contents
MDM Templates
First-Time Seizure
Patient presents after a witnessed generalized tonic-clonic seizure with appropriate postictal period and return to baseline. No history of prior seizure. No preceding trauma, fever, or immunosuppression. No history of alcohol abuse or toxic ingestion.
Presentation consistent with first-time unprovoked seizure. Given return to baseline with normal neurologic exam, low suspicion for stroke, CNS infection, intracranial hemorrhage, or mass lesion. Workup directed at identifying a provoking cause.
Plan: Discharge with neurology follow-up for outpatient EEG and MRI. Driving restrictions discussed. Return for recurrent seizure, persistent confusion, headache, fever, or focal weakness.
Known Epilepsy — Breakthrough Seizure
Patient with known seizure disorder presents after a seizure consistent with their typical semiology. Most likely precipitant is medication nonadherence, though infection, sleep deprivation, and medication interaction also considered. Patient has returned to baseline.
Given typical semiology with return to baseline and no new focal deficits, low suspicion for new intracranial pathology. No features to suggest status epilepticus, CNS infection, or structural lesion.
Plan: AED levels checked if applicable. Discharge with neurology follow-up for medication optimization. Return for recurrent seizures, prolonged confusion, or new neurologic symptoms.
Status Epilepticus
Patient presents with continuous seizure activity lasting greater than 5 minutes, or recurrent seizures without return to baseline between episodes. This is status epilepticus requiring emergent treatment.
Status epilepticus carries significant morbidity and mortality from direct neuronal injury, aspiration, rhabdomyolysis, hyperkalemia, and hyperthermia. Immediate benzodiazepine administration is the priority. Workup directed at identifying and treating the underlying cause while controlling seizure activity.
If refractory to first- and second-line agents: Refractory status epilepticus. Intubation for airway protection and initiation of continuous IV anesthetic infusion. Neurology consulted regarding continuous EEG monitoring and ICU admission.
Plan: Benzodiazepines administered. Second-line AED loaded. Neurology consulted. Admit to ICU for continuous EEG monitoring.
Clinical Education
Approach to Seizure in the ED
Check glucose immediately. Hypoglycemic seizures resolve with dextrose, not benzodiazepines. This is the single fastest reversible cause.[1]
Check sodium. Hyponatremic seizures are treated with 3% hypertonic saline (100–150 mL bolus), not AEDs. Two amps of sodium bicarbonate is a reasonable ED alternative if 3% NS is not immediately available (~150 mL of approximately 3% NaCl equivalent).
The postictal period is your friend. A patient who had a witnessed generalized seizure and is now slowly waking up over 15–30 minutes is behaving normally. A patient who is not improving at 30–60 minutes needs further workup — consider nonconvulsive status, intracranial pathology, or toxicologic cause.
Provoked vs Unprovoked
This distinction drives everything — workup, treatment, and prognosis. A provoked seizure has an identifiable acute cause (hypoglycemia, hyponatremia, alcohol withdrawal, drug toxicity, acute head trauma, CNS infection). An unprovoked seizure has no identifiable acute precipitant and represents a lower seizure threshold or structural predisposition.[2]
Provoked seizures have low recurrence risk (3–10%) once the provoking factor is treated. They generally do not require AED initiation or long-term neurology follow-up for epilepsy, though they need treatment of the underlying cause.
First unprovoked seizure: recurrence risk is 30–50% over 2 years. 60–70% of recurrences happen within 6 months. After a second unprovoked seizure, recurrence risk rises to 70–80%, justifying the diagnosis of epilepsy. Starting an AED after a first unprovoked seizure is a shared decision between the patient and neurologist.[2]
Status Epilepticus Management
First-line: Benzodiazepines. Lorazepam 0.1 mg/kg IV (max 4 mg per dose) is preferred. Midazolam 10 mg IM is the first-line alternative when there is no IV access — per the RAMPART trial, IM midazolam is noninferior to IV lorazepam.[3]
Second-line: AED loading. If seizure continues after 2 doses of benzodiazepine, load a second-line agent while preparing for intubation. Options: levetiracetam (Keppra) 60 mg/kg IV (max 4500 mg), fosphenytoin 20 mg PE/kg IV, or valproate 40 mg/kg IV. Per the ESETT trial, all three are equivalent.[4]
Third-line (refractory): Continuous IV anesthetic. If still seizing after first- and second-line agents, intubate and start a continuous infusion. Options: midazolam 0.2 mg/kg load then 1 mg/kg/hr, propofol 1 mg/kg load then 50–80 mcg/kg/min, or ketamine 5 mg/kg/hr. Continuous EEG required. ICU admission mandatory.
| Line | Agent | Dose |
| 1st | Lorazepam IV or Midazolam IM | 0.1 mg/kg IV (max 4 mg) or 10 mg IM |
| 2nd | Levetiracetam, Fosphenytoin, or Valproate | Keppra 60 mg/kg, Fosphenytoin 20 PE/kg, or VPA 40 mg/kg |
| 3rd | Continuous anesthetic infusion + intubation | Midazolam, propofol, or ketamine drip |
Recurrence Risk
Not all first seizures are created equal. Factors that increase recurrence risk include abnormal EEG, structural brain lesion on MRI, nocturnal seizure, and focal onset. A patient with a normal neurologic exam, normal CT, and a clear provoking cause has the lowest risk. A patient with a focal seizure and no clear trigger has the highest.[2]
Driving restrictions vary by state but generally require a seizure-free interval of 3–12 months. Discuss this with the patient at discharge — it’s a safety issue they need to understand before they leave.
When to LP
LP is not routine after a seizure. Consider LP in patients who are immunocompromised, febrile, have persistent altered mentation, have signs of meningismus, or present with status epilepticus without clear cause. HIV-positive patients with a first seizure warrant LP and imaging given the broad differential (toxoplasmosis, cryptococcal meningitis, lymphoma).[1]
Disposition
Discharge: First-time seizure with return to neurologic baseline, normal CT (if obtained), no ongoing seizure activity, and reliable follow-up with neurology for outpatient EEG and MRI. Breakthrough seizure in known epilepsy with return to baseline and no concerning features.
Admit: Status epilepticus, persistent AMS that does not clear, new focal neurologic deficits, abnormal CT, concern for CNS infection, first seizure in a high-risk patient (immunocompromised, anticoagulated, known malignancy), or recurrent seizures despite AED loading.
References
- Huff JS, Morris DL, Kothari RU, Gibbs MA. Emergency department management of patients with seizures: a multicenter study. Acad Emerg Med. 2001;8(6):622-628. PubMed
- Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults. Neurology. 2015;84(16):1705-1713. PubMed
- Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus (RAMPART). N Engl J Med. 2012;366(7):591-600. PubMed
- Kapur J, Elm J, Chamberlain JM, et al. Randomized trial of three anticonvulsant medications for status epilepticus (ESETT). N Engl J Med. 2019;381(22):2103-2113. PubMed
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