1st Time Seizure

Diagnosis/symptom

Signs and symptoms Symptoms before seizures (preictal)

• Precipitating events: illness, trauma, toxins, sleep deprivation
• Preceding aura: strange smell or taste, change in vision, tingling sensation
• Behavior/ mood before and after Symptoms during seizure (ictal) Retention or loss of awareness during event
• Cry, gasp, garbled or slurred speech
• Head and eye deviation, posturing, stiffening, rhythmic jerking 
• Automatisms: purposeless repetitive movements (lip smacking, picking at clothes)
• Movements or whole body or focal
• Change in breathing or cyanosis
• Drooling, pupillary dilatation, incontinence Symptoms after seizure (postictal)
• Lack of recall of event, confusion, lethargy
• Nausea or vomiting
• Headache
• Muscle aches
• Transient focal weakness (Todd’s paralysis)

Causes

• Hypoglycemia
• electrolyte disturbances infection
• trauma
• toxic exposure
• stroke
• acquired or genetic cause associated with an anatomic or pathologic abnormality such as developmental malformation or neurocutaneous syndromes

Referring provider’s initial evaluation and management:

Diagnosis and Treatment

• EEG: Regular. CHW schedulers will give pt/family instructions.
• Laboratory tests: routine lab testing is not recommended, consideration for lab tests should be based on individual clinical circumstances. May consider if indicated by clinical presentation:
  
  • Basic serum studies- complete blood count, glucose, electrolytes, calcium, and magnesium
  • Toxicology screen
  • Basic metabolic evaluation if suspect a metabolic abnormality in a neonate with serum ammonia, serum lactate and pyruvate, serum amino acids, and urine organic acids.
  • Lumbar puncture (LP) in patients with clinical concern for meningitis or encephalitis (< 6 mo. old, Kernig or Brudzinski sign) or altered mental status. 
• Neuroimaging: consider for certain clinical circumstances such as focal neurological symptoms on examination, significant cognitive or motor impairment of unknown etiology, or seizures with partial onset
  
  • MRI- preferred modality on non-urgent basis
  • CT for emergent imaging- postictal persistent focal deficit, patient not returning to baseline, history of trauma
  • EKG maybe needed in certain circumstances

When to initiate referral/ consider refer to Neurology Clinic:

• Abnormal EEG
• Second unprovoked seizure
• Focal symptoms
• Abnormal neurological examination

What can referring provider send to Neurology Clinic? 

1. Using Epic

• Please complete the external referral order In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:
• Urgency of the referral
• What is the key question you would like answered? Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414-607-5288)
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems.

Specialist’s workup will likely include:

• Labs
• Imaging
• EEG