Almost one-third of people with epilepsy do not gain complete seizure control by standard therapy.2 These individuals frequently present to the ED after typical seizures. The ED physician must determine whether the patient has merely had a typical seizure, which may require no acute therapy, or whether the seizure was atypical or due to some other condition that might require immediate evaluation and treatment.

As with many other aspects of neurology, the key to appropriate diagnosis and treatment is the history. Unfortunately, history is often lacking in this setting, as individuals with epilepsy are often confused after seizures, reliable historians are often hard to contact in the ED, and patients are usually brought in by ambulance, leaving witnesses behind.

The simplest scenario is the one in which the patient is brought to the ED after a seizure and returns to his or her normal interictal baseline by the time of assessment by the ED physician. If the patient is completely normal, recounts a typical aura before seizure onset, has a normal examination and no fever, and has appropriate medical care in place, then the visit may only require sending serum for electrolytes, complete blood count (CBC), and AED levels and calling the patient's physician to arrange appropriate follow- up. It is preferable in such circumstances to discharge the patient into the care of family, friends, or other caretakers who can observe the patient and initiate a return to the ED at the first sign of any recurrence, illness, or unusual change in behavior.

Such clear-cut cases are relatively rare, however, because most individuals with seizures usually become cognizant of their seizures and the events that surround them only by hearing accounts from witnesses or by surmising that they have occurred after they awaken in the ED with sore muscles, a lacerated tongue, or urine incontinence. This complicates their ED care and decisions about whether to release them or admit them to the hospital.

Issues that complicate the care of epilepsy patients in the ED after seizures usually pertain to one of the following deviations from their typical seizures:

When deviations from the previously mentioned perfect scenario occur, always err on the side of caution. Admit the patient if there is any significant concern or unexplained findings. This approach may result in admitting individuals to the hospital who could probably go home, but it means that serious conditions are unlikely to remain untreated.

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535. With permission from Elsevier (

Authored By: 
Steven J. Kolb Md PhD
Brian Litt MD
Reviewed By: 
Steven C. Schachter MD
Saturday, May 1, 2004