Name: Seizure — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most seizures stop on their own, and a well-appearing patient back at baseline needs a focused workup, not a shotgun one. The defensible chart shows you excluded the treatable provoked causes, considered non-convulsive status when recovery lagged, and gave explicit driving and safety counseling.

▸Critical pathway

Original, evidence-based synthesis — the critical diagnoses you cannot miss, the tests that catch them, and the interventions that can’t wait. Apply local protocol and judgment.

① Immediate

Protect the airway, give oxygen, obtain IV access, and check a fingerstick glucose immediately.
For ongoing seizure: benzodiazepine first-line, repeated, then a second-line agent (e.g., levetiracetam, fosphenytoin, valproate); treat as status epilepticus at 5 minutes.

② Critical tests

Fingerstick glucose and electrolytes (including sodium), calcium, magnesium
Pregnancy test in patients of reproductive potential (eclampsia)
Non-contrast head CT for first seizure, trauma, focal deficit, or persistent altered mentation
Toxicology and antiepileptic levels as indicated

③ Can’t-miss → act

Status epilepticus

Trigger: Seizure >5 minutes or repeated seizures without recovery
Test: Clinical; EEG for nonconvulsive status
Intervention: Escalating benzodiazepines then second-line agents; anesthesia for refractory cases

Hypoglycemia

Trigger: Low fingerstick glucose
Test: Fingerstick glucose
Intervention: IV dextrose (thiamine if malnourished)

Eclampsia

Trigger: Pregnant or postpartum with seizure
Test: Pregnancy test and blood pressure
Intervention: IV magnesium sulfate and urgent OB involvement

Intracranial hemorrhage / mass

Trigger: Focal deficit, trauma, or persistent altered mentation
Test: Non-contrast head CT
Intervention: Neurosurgery; reverse coagulopathy

CNS infection

Trigger: Fever with seizure or meningismus
Test: Lumbar puncture
Intervention: Early empiric antibiotics ± acyclovir

④ Disposition

A first unprovoked seizure with full recovery and a normal workup can often be discharged with neurology follow-up and driving precautions; status, a structural cause, or incomplete recovery is admitted.

01What's at stake

The misses cluster in two places: a reversible provoked cause treated as "just a seizure" (hypoglycemia checked too late, hyponatremia, eclampsia, an intracranial bleed, meningitis, or a toxin), and the patient who never truly wakes up — non-convulsive status epilepticus presenting as a prolonged "postictal" state or coma. And the cheapest indefensible miss is forgetting to tell the patient not to drive.

02Can't-miss provoked causes

Hypoglycemia — check a glucose with the vitals on every seizing/postictal patient.
Hyponatremia — psychiatric water intoxication, renal failure, multiple comorbidities.
Eclampsia — pregnant or up to 6 weeks postpartum; magnesium is first-line.
Intracranial hemorrhage / structural lesion — anticoagulation, trauma; image first seizures.
CNS infection — fever, headache, immunocompromise; any CSF pleocytosis = meningitis until proven otherwise.
Toxins — TCA (avoid phenytoin), INH (give pyridoxine), sympathomimetics, withdrawal.
Non-convulsive status epilepticus — prolonged altered mentation/coma; needs EEG.

03Workup — focused, not shotgun

Otherwise-healthy adult, first seizure, back to baseline: glucose, sodium, and a pregnancy test — that's the required lab set (ACEP). Broaden only for persistent AMS, status, fever, or a new deficit.
Non-contrast CT for a first nonfebrile seizure once stabilized (a first alcohol-related seizure still gets worked up — history/exam don't predict the lesion).
LP for fever, severe headache, persistent AMS, or immunocompromise.
EEG when recovery lags or coma is unexplained — suspect non-convulsive status.
Postictal confusion should clear in <1 hour; a persistent deficit (Todd paralysis that won't resolve) needs a structural workup.

Skip the typing

Work the case in the Seizure Workup — it records glucose, the neuro exam, the pregnancy test, metabolic labs, and ASM adherence/level, and assembles an MDM that documents the provoked causes were considered and the safety counseling given.

04Status epilepticus — the timed ladder

Define it early: a seizure ≥5 minutes (or recurrent seizures without return to baseline) is status — don't wait 30 minutes.
First-line, benzodiazepine: lorazepam 0.1 mg/kg IV (up to 4 mg), repeat in 5–10 min; no IV access → IM midazolam 10 mg (RAMPART).
Second-line: fosphenytoin 20 PE/kg (or phenytoin 20 mg/kg, non-glucose line, cardiac monitoring), valproate, or levetiracetam.
Refractory: intubate + continuous EEG; midazolam, propofol, or pentobarbital infusion. Special cases: INH → pyridoxine; eclampsia → magnesium.
Oxygenation and perfusion come first — hypoxia and hypotension drive the worst outcomes.

05Disposition & counseling

A first unprovoked seizure with return to baseline does not mandate admission — individualize on follow-up and social risk; don't routinely start an AED in the ED for a first seizure (involve neurology).
Explicitly counsel against driving (and swimming, heights, machinery) — and document it. Know your state's reporting rules.
Known epilepsy with a breakthrough seizure: address adherence/level and restart the medication; close neurology follow-up.

06What to document

▼ weak

"Seizure, now postictal, improving. AED level low. Discharged, f/u neuro."

▲ defensible

"Witnessed generalized convulsion per EMS; glucose 104 at triage. Returned to baseline within 30 min — no persistent deficit. Sodium and pregnancy test normal; no fever, head trauma, anticoagulation, or focal findings. Known epilepsy, missed doses x2 days — most consistent with a breakthrough seizure; medication restarted. Hypoglycemia, hyponatremia, intracranial process, infection, and toxic causes considered and excluded. Counseled explicitly not to drive or swim until cleared by neurology; verbalized understanding. Return for recurrent or prolonged seizure, fever, or persistent confusion."

07Where charts fail

Not documenting the glucose check on a seizing patient.
Calling a coma or prolonged "postictal" state benign without considering non-convulsive status.
Attributing a breakthrough seizure to a low AED level and closing the workup.
Assuming the patient knows not to drive — counsel and document it explicitly.
Presuming a first alcohol-related seizure is withdrawal without imaging.

08Sources

Teran F, Harper-Kirksey K, Jagoda A. Clinical decision making in seizures and status epilepticus. Emergency Medicine Practice (EB Medicine). 2015;17(1).
Huff JS, Melnick ER, Tomaszewski CA, et al. ACEP clinical policy: adult patients presenting to the ED with seizures. Ann Emerg Med. 2014;63(4):437-447.
Treiman DM, Meyers PD, Walton NY, et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med. 1998;339(12):792-798.
Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus (RAMPART). N Engl J Med. 2012;366(7):591-600.
Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23.

Seizure: documentation that holds up