There unfortunately is very little recent literature about the best workup approach. In 1994, the American College of Emergency Physicians (ACEP) published a Clinical Policy based on expert consensus. The EM Clinics of North America series also just published a review on the topic. The bottom-line is that there are two types of workup approaches.
For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes:
For the uncomplicated cases (age less than 40 years, afebrile, no comorbidities, no neurologic deficits), the workup is fairly minimal, which includes:
- Glucose and electrolytes
- Urine pregnancy test, if appropriate
- +/- Urine toxicology screen
- Head CT (noncontrast)
Otherwise, the more complex cases require a more extensive workup, which may include a lumbar puncture in the setting of a fever, severe headache, immunocompromised status, or persistent altered mental status.
Pearl: Be sure you obtain a head CT for patients who you think are presenting with a simple new-onset, alcohol-withdrawal seizure. One study showed that 6.2% of these patients actually have a significant lesion on CT (eg. bleed, mass).
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Reference
ACEP Clinical Policies Committee, Clinical Policies Subcommittee on Seizures. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Annals of EM. 2004, 43(5), 605-25. PMID: 15111920
Jagoda A, Gupta K. The emergency department evaluation of the adult patient who presents with a first-time seizure. EM Clinics of North America. 2011, 29(1), 41-9. PMID: 21109101
