1st Time Seizure

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Updated by: Dr. Hecox
Updated on: 1/2018


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)


  • 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