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Approach to first seizure

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Ongoing or recurring seizure at 5 minutes: status epilepticus, benzodiazepine now
    • Airway and lateral position; do not force anything between teeth
    • Hypoglycemia: the reversible mimic that must be measured, not assumed
    • Eclampsia in any pregnant patient: magnesium, not standard algorithms
    • Head trauma, anticoagulation, or focal onset: structural cause until imaged

  2. History that discriminates

    • A witness account is the single highest-yield investigation: onset, spread, duration, eyes, color
    • Before: aura, warning, position, circumstances (standing in a hot queue points elsewhere)
    • After: confusion measured in minutes to hours (post-ictal) versus immediate clarity (syncope)
    • Tongue biting (lateral), incontinence, shoulder injury: supportive, none decisive alone
    • Alcohol and withdrawal timing, drugs, sleep deprivation, prior events never reported

  3. Examination

    • GCS trend: a post-ictal patient should be clearing; one who is not is a threat
    • Focal neurology (Todd's paresis versus new structural deficit)
    • Tongue lateral border, shoulders, head for injury
    • Fever and neck stiffness where infection is credible

  4. Problem representation

    A witnessed generalized convulsion with lateral tongue biting and thirty minutes of confusion in a young adult after three nights without sleep (points at provoked seizure) versus collapse with pallor and seconds-long twitching on standing, clear immediately (points at syncope with myoclonic jerks).

  5. Differential, by mechanism

    Provoked

    • Hypoglycemia
    • Hyponatremia and other electrolytes
    • Alcohol withdrawal
    • Drugs and toxins
    • Sleep deprivation

    Structural

    • Tumor
    • Stroke or bleed
    • Trauma
    • Prior cortical scar

    Infective / inflammatory

    • Meningitis
    • Encephalitis (autoimmune included)

    Mimics

    • Convulsive syncope
    • Functional events
    • Migraine with aura
    • TIA

  6. Investigations

    • Glucose at the bedside; sodium, calcium, magnesium in the first panel
    • ECG in every first seizure: the long QT that faints and jerks is a seizure mimic that kills
    • CT head acutely for trauma, anticoagulation, focal onset, or failure to clear; MRI electively
    • EEG shapes recurrence risk and classification, rarely the acute diagnosis
    • Prolactin is not a reliable discriminator; do not lean on it

  7. Interpretation

    • The story splits seizure from syncope better than any test: prodrome, color, duration, and recovery
    • A provoked seizure with a corrected provoker is not epilepsy and mostly does not need maintenance drugs
    • Failure to wake as expected is its own emergency: non-convulsive status, hidden bleed, or infection

  8. Next steps

    • Treat the provoker; involve neurology for recurrence-risk counselling before starting maintenance therapy
    • Driving and safety advice is a legal duty in most jurisdictions: document what was said
    • Clear return precautions for the patient and whoever lives with them

Connected

TopicThe sodium behind seizuresAlgorithmHyponatremia pathwayApproachThe patient who does not clear

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