Bedside Rounds

First seizure and status epilepticus: workup and approach

A seizure lasting 5 minutes or longer, or repeated seizures without recovery, is status epilepticus and needs immediate benzodiazepine then a second-line antiseizure medication. After a first seizure, look for provoking causes (metabolic, toxic, structural, infectious) and assess recurrence risk.

Presenting complaint Adult · US guidelines Draft · awaiting physician review
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01Orient

What's new in the evidence

  • ACEP 2024 clinical policy: levetiracetam, fosphenytoin and valproate are equally acceptable second-line agents after benzodiazepines (ESETT)
  • Underdosed benzodiazepines are the most common error; give a full dose early
  • Observational data suggest a levetiracetam ceiling around 30–40 mg/kg; the recommended loading dose is unchanged

Differential diagnoses

  1. Provoked seizure: hypoglycemia, hyponatremia, hypocalcemia, alcohol or benzodiazepine withdrawal, drugs (can't miss)
  2. Structural lesion: stroke, hemorrhage, tumor, trauma (can't miss)
  3. CNS infection: meningitis, encephalitis (can't miss)
  4. First unprovoked seizure or new epilepsy
  5. Syncope with myoclonic jerks
  6. Functional (psychogenic nonepileptic) seizure
  7. Cardiac arrhythmia

02Assess

Risk scores and decision tools

  • Seizure duration (≥5 minutes = status epilepticus)
  • Recurrence risk after a first seizure: abnormal EEG, structural lesion, nocturnal seizure
  • Glucose, sodium, calcium, magnesium and drug levels

Key history questions

  • Witness account: onset, duration, movements, eyes open, tongue biting, incontinence
  • Postictal confusion and duration
  • Prior seizures; antiseizure medication adherence
  • Alcohol, drugs, sleep deprivation, new medications (bupropion, tramadol, antibiotics)
  • Head injury, headache, fever, immunosuppression
  • Pregnancy (eclampsia)

Examination findings

  • Airway, breathing, vital signs, glucose
  • Lateral tongue bite, injuries, posterior shoulder dislocation
  • Focal deficits, meningism, papilledema
  • Ongoing subtle seizure activity (nystagmus, twitching) if not waking

03Investigate

Initial investigations

  • Point-of-care glucose
  • BMP, calcium, magnesium, CBC
  • Antiseizure drug levels if applicable; urine drug screen, alcohol level
  • Pregnancy test; ECG
  • CT head (non-contrast) for a first seizure

Advanced investigations

  • MRI brain with epilepsy protocol
  • EEG (urgent continuous EEG if not returning to baseline)
  • Lumbar puncture if fever, immunosuppression or meningism

04Treat

Immediate management

  • Airway, oxygen, recovery position, glucose check
  • Status epilepticus at 5 minutes: lorazepam 4 mg IV (may repeat once), or midazolam 10 mg IM if no IV
  • Second line if seizures continue: levetiracetam 60 mg/kg IV (max 4500 mg), fosphenytoin 20 mg PE/kg, or valproate 40 mg/kg (max 3000 mg)
  • Thiamine before glucose when indicated

First-line treatment

  • Treat the provoking cause
  • Refractory status: intubation and anesthetic infusion (midazolam or propofol) with continuous EEG

Second-line treatment

  • Start antiseizure medication after a first unprovoked seizure if recurrence risk is high (abnormal EEG, structural lesion, nocturnal seizure); shared decision

Specialist referrals

  • Neurology
  • ICU for status epilepticus

05Disposition

Admission criteria

  • Status epilepticus or cluster seizures
  • Not back to baseline
  • Provoking cause needing treatment, structural lesion or infection

Safe discharge criteria

  • Back to baseline, normal glucose, electrolytes and CT
  • Responsible adult present; neurology follow-up and EEG/MRI arranged

Follow-up timing

  • Neurology clinic within 1–2 weeks

Patient instructions

  • No driving until cleared under your state's law
  • Avoid swimming or bathing alone, heights and operating machinery
  • Call 911 for a seizure lasting over 5 minutes

Monitoring

  • Neuro checks; seizure precautions; airway

Clinical pearls and pitfalls

  • Most seizures stop within 2 minutes; prolonged seizures become harder to stop, so treat at 5 minutes
  • Prolactin and lactate add little in routine practice

RefGuidelines and landmark evidence

For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.

Calculators for this workup

Glasgow Coma ScaleCIWA-Ar
Acetaminophen overdoseAcute abdominal painAcute aortic dissectionAcute cholangitis and choledocholithiasisAcute decompensated heart failureAcute diverticulitisAcute dizziness and vertigoAcute ischemic stroke and TIAAcute kidney injuryAcute pancreatitisAcute pericarditisAdrenal crisisAlcohol withdrawalAlcohol-associated hepatitisAnaphylaxisAnemia in hospitalized adultsAsthma exacerbationAtrial fibrillation with rapid ventricular responseBacterial meningitisCellulitisChest painClostridioides difficile infectionCommunity-acquired pneumoniaCOPD exacerbationDecompensated cirrhosis (ascites, SBP, hepatic encephalopathy)Deep vein thrombosisDelirium / acute confusionDiabetic foot infection and osteomyelitisDiabetic ketoacidosisFebrile neutropeniaHypercalcemiaHyperglycemia in hospitalized adultsHyperkalemiaHypernatremiaHyperosmolar hyperglycemic state (HHS)Hypertensive emergencyHypoglycemiaHypokalemiaHyponatremiaInfective endocarditisLower GI bleedMajor bleeding on anticoagulants (reversal)Malignant spinal cord compressionNSTEMI and non-ST-elevation ACSOpioid overdose and opioid use disorderPulmonary embolismPyelonephritis and complicated UTIRhabdomyolysisSepsisShortness of breathSickle cell vaso-occlusive crisisStaphylococcus aureus bacteremiaSymptomatic bradycardia and heart blockSyncopeThrombocytopenia (including TTP, HIT and ITP)Thunderclap headache (rule out subarachnoid hemorrhage)Thyroid stormTumor lysis syndromeUpper GI bleed