Postictal State and Seizure Recurrence ConcernAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

590 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Transient Neurologic Deficits Acute Aphasia And Speech Disturbance Acute Confusion And Delirium Postictal State And Seizure Recurrence Concern Seizure Acute Vision Loss New Tremor And Involuntary Movements Headache Vertigo Acute Weakness Or Numbness Gait Instability And Ataxia

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx91

Presenting context

›Postictal and recurrence context

›Witnessed seizure description

›Unwitnessed event

›Found down

›Baseline neurocognitive function

›Return to baseline timing

OPQRST

›Onset

›Last known normal time

›Time of event

›Time last seizure ended

›Time to first purposeful response

›Provocation or palliation

›Sleep deprivation

›Missed antiseizure medications

›Alcohol withdrawal window

›Recent illness

›Fever

›Photostimulation exposure

›Hyperventilation exposure

›Quality

›Confusion

›Somnolence

›Agitation

›Aphasia

›Amnesia

›Headache

›Focal weakness

›Region or radiation

›Focal motor onset region

›Sensory aura distribution

›Headache location

›Tongue injury location

›Severity

›Persistent inability to follow commands

›Need for restraints

›Recurrent seizures in ED

›Respiratory compromise during event

›Timing

›Seizure duration estimate

›Cluster pattern

›Frequency change from baseline

›Prior postictal duration typical

Associated features

›Peri ictal and postictal features

›Tongue bite

›Urinary incontinence

›Cyanosis

›Prolonged snoring respirations

›Postictal headache

›Postictal myalgia

›Todd paralysis duration

›New focal neurologic deficit

Prior seizure history

›Epilepsy and prior events

›First lifetime seizure concern

›Known epilepsy syndrome

›Prior status epilepticus

›Typical semiology and triggers

›Prior EEG and neuroimaging results

Recent exposures and triggers

›Reversible precipitants

›Alcohol use pattern

›Recent cessation of alcohol

›Stimulants

›Cocaine

›Amphetamines

›Synthetic cannabinoids

›Medication toxicity exposure

›Bupropion exposure

›Tramadol exposure

›Isoniazid exposure

›Diphenhydramine exposure

›Organophosphate exposure

Infectious and inflammatory context

›CNS infection and inflammation context

›Fever

›Neck pain

›Rash

›Immunocompromised status

›Recent travel

›Recent antimicrobial use

Trauma and vascular context

›Head and vascular context

›Head trauma

›Anticoagulant use

›Thunderclap headache

›Persistent severe headache

›Pregnancy or postpartum

›Known aneurysm

›Known arteriovenous malformation

Pediatric and adolescent specific

›Age specific context

›Febrile seizure pattern

›Ingestions risk

›School or sports head injury

›Developmental delay baseline

›Non accidental trauma concern

02Alarm Features/alarm30

Immediate threats

›Time critical seizure syndromes

›Ongoing convulsive seizure

›Suspected nonconvulsive status epilepticus

›Recurrent seizures without return to baseline

›New persistent focal deficit

›Airway compromise

›Hypoxemia

›Aspiration

High risk vitals

›Dangerous physiology

›Systolic hypotension

›Severe hypertension with neurologic symptoms

›Fever

›Hypothermia

›Persistent hypoxemia

›Hypoventilation

High risk history triggers

›Cannot miss contexts

›First lifetime seizure with persistent altered mental status

›Pregnancy or postpartum seizure

›Immunocompromised with seizure

›Recent head trauma

›Anticoagulant or antiplatelet with head injury

›Known malignancy

›Suspected toxin ingestion

Escalation triggers

›Resuscitation activation thresholds

›Seizure longer than 5 minutes

›Second seizure without baseline recovery

›Persistent GCS less than 13 after expected postictal window

›Refractory agitation preventing assessment

›Hyperthermia with rigidity

›Cardiac arrhythmia concern

03Medications/meds27

Antiseizure regimen

›Chronic antiseizure medications

›Name and formulation

›Dose and schedule

›Last dose time

›Recent dose change

›Recent missed doses

High risk medication exposures

›Pro convulsant and interacting agents

›Bupropion

›Tramadol

›Theophylline

›Clozapine

›Lithium

›SSRIs

›TCAs

›Fluoroquinolones

›Isoniazid

Sedatives and withdrawal agents

›Withdrawal relevant agents

›Benzodiazepines

›Barbiturates

›Baclofen

›Alcohol

Anticoagulants and antiplatelets

›Bleeding risk agents

›Warfarin

›Direct oral anticoagulants

›Heparin

›Aspirin

›P2Y12 inhibitors

04Diet/diet15

Intake and metabolic risks

›Nutritional and hydration status

›Poor oral intake

›Vomiting

›Diarrhea

›Dehydration risk

›Fasting

›Keto diet exposure

Caffeine and stimulants

›Sympathomimetic exposures

›Energy drinks

›High caffeine intake

›Pre workout supplements

Alcohol exposure

›Alcohol pattern

›Heavy use

›Last drink time

›Withdrawal risk window

05Review of Systems/ros27

Neurologic

›Neuro symptoms

›Headache

›Neck stiffness

›Photophobia

›Persistent confusion

›Focal weakness

›Speech disturbance

›Visual loss

›New gait instability

Infectious and inflammatory

›Infection symptoms

›Fever

›Chills

›Rash

›Recent URI symptoms

›Dysuria

Cardiorespiratory

›Cardiopulmonary symptoms

›Chest pain

›Palpitations

›Dyspnea

›Syncope prodrome

Toxicologic and endocrine

›Metabolic and toxin symptoms

›Polyuria

›Polydipsia

›Weight loss

›Tremor

›Diaphoresis

›Heat exposure

06Collateral History and Family History/chafh14

Collateral sources

›Witness and collateral reliability

›EMS report

›Family report

›Video of event

›Baseline mental status confirmation

Family history

›Seizure and sudden death history

›Epilepsy in first degree relatives

›Sudden unexplained death

›Channelopathy history

›Early stroke history

Social support

›Supervision and safety reliability

›Responsible adult available

›Ability to observe for recurrence

›Ability to obtain medications

07Risk Factors/rf24

Structural and vascular

›Brain lesion risk

›Prior stroke

›Intracranial hemorrhage history

›Brain tumor history

›AVM or aneurysm history

›Recent head trauma

Metabolic and systemic

›Physiologic provocation risks

›Diabetes mellitus

›Chronic kidney disease

›Chronic liver disease

›Electrolyte disorders history

›Poor sleep

Toxicologic

›Exposure risks

›Substance use disorder

›Recent medication overdose risk

›Occupational toxin exposure

Pregnancy related

›Obstetric risks

›Pregnancy

›Postpartum within 6 weeks

›Preeclampsia history

Pediatric and adolescent

›Age related risks

›Febrile illness

›Ingestions

›Non accidental trauma risk

08Differential Diagnosis/ddx66

Life threatening

›Immediate life threats

›Status epilepticus

›Persistent altered mental status

›Recurrent seizures without baseline recovery

›Nonconvulsive status epilepticus

›Persistent confusion

›Subtle motor automatisms

›Hypoglycemia

›Diaphoresis

›Low point of care glucose

›CNS infection

›Fever

›Neck stiffness

›Intracranial hemorrhage

›Head trauma

›Anticoagulants

›Acute ischemic stroke with seizure

›New focal deficit

›Aphasia

›Subarachnoid hemorrhage

›Thunderclap headache

›Meningismus

›Eclampsia

›Pregnancy or postpartum

›Severe hypertension

›Toxic ingestion

›QRS widening on ECG

›Anticholinergic toxidrome

Common

›Common causes

›Postictal state

›Typical semiology

›Gradual improvement over time

›Breakthrough seizure from missed doses

›Nonadherence

›Vomiting or malabsorption

›Alcohol withdrawal seizure

›Tremor

›Autonomic hyperactivity

›Sleep deprivation provoked seizure

›Recent short sleep

›Shift work

›Infection provoked seizure

›Fever

›Systemic illness

Less common

›Less common and mimics

›Psychogenic nonepileptic event

›Asynchronous movements

›Eye closure with resistance

›Syncope with convulsive movements

›Presyncope prodrome

›Rapid recovery without postictal confusion

›Hyponatremia

›Diuretic use

›Polydipsia

›Hyperglycemic hyperosmolar state

›Marked dehydration

›Very high serum osmolality

›Medication toxicity

›Lithium

›Theophylline

›Encephalitis

›Behavioral change

›New seizures

›Cerebral venous thrombosis

›Pregnancy or postpartum

›Persistent headache

09Past Medical History/pmh20

Neurologic history

›Epilepsy and neurologic comorbidity

›Epilepsy diagnosis

›Prior EEG abnormalities

›Prior neuroimaging abnormalities

›Prior neurosurgery

›Prior CNS infection

Medical comorbidities

›Systemic conditions

›Diabetes

›Renal disease

›Hepatic disease

›Heart disease

›Substance use disorder

Prior ED utilization

›Prior acute care patterns

›Recent ED visits for seizures

›Prior ICU admissions for status epilepticus

›Prior intubation for seizures

Baseline function

›Baseline status

›Baseline mental status

›Baseline mobility

›Caregiver dependence

10Physical Exam/exam43

General and vitals

›Global assessment

›Airway patency

›Work of breathing

›Oxygen saturation trend

›Temperature

›Persistent tachycardia

Neurologic

›Neuro exam focus

›Level of consciousness

›Orientation

›Command following

›Speech

›Pupils

›Extraocular movements

›Facial symmetry

›Motor strength

›Pronator drift

›Sensory asymmetry

›Reflexes

›Coordination

›Gait when safe

Postictal patterns

›Features supporting postictal state

›Gradual improvement

›Sleepiness

›Headache

›Todd paralysis resolving

Trauma and toxidrome screen

›Injury and tox findings

›Scalp hematoma

›Signs of basilar skull fracture

›Tongue lacerations

›Shoulder dislocation

›Track marks

›Anticholinergic signs

›Diaphoresis

›Hyperreflexia

Cardiopulmonary

›Heart and lungs

›Arrhythmia signs

›Heart murmur

›Aspiration findings

›Wheeze

Meningeal signs

›Meningitis and encephalitis clues

›Nuchal rigidity

›Photophobia

›Rash

11Lab Studies/labs37

Point of care testing

›Immediate bedside tests

›Capillary glucose

›Pregnancy test when relevant

›Temperature recheck trend

Core serum studies

›High yield screening labs

›Sodium

›Potassium

›Calcium

›Magnesium

›Creatinine

›Urea

›AST

›ALT

›Bilirubin

›CBC

Acid base and hypoxemia

›Respiratory and metabolic physiology

›Venous blood gas

›Arterial blood gas when ventilatory failure concern

›Lactate trend

Toxicology and levels

›Exposure directed studies

›Ethanol level when relevant

›Acetaminophen level when ingestion possible

›Salicylate level when ingestion possible

›Urine drug screen local protocol dependent

Antiseizure medication levels

›Level guided management

›Phenytoin level

›Valproate level

›Carbamazepine level

›Phenobarbital level

Infection evaluation

›Systemic infection evaluation

›Blood cultures when febrile and unstable

›CRP local protocol dependent

›Procalcitonin local protocol dependent

Interpretation pitfalls

›Common traps

›Lactate elevation after generalized tonic clonic seizure

›Leukocytosis after seizure

›Mild metabolic acidosis after seizure

12Imaging/img24

Scoring Systems

›Risk and severity tools

›Status Epilepticus Severity Score

›Limited validation across settings

›2HELPS2B for EEG seizure risk

›Use only with EEG availability

MRI

›MRI brain considerations

›First unprovoked seizure outpatient pathway when stable

›Concern for encephalitis

›Concern for tumor

›Concern for cortical dysplasia

›CT head noncontrast

›New focal deficit

›Persistent altered mental status

›Head trauma

›Anticoagulant use

›Immunocompromised status

›Concern for intracranial hemorrhage

›CT angiography head and neck

›Suspected subarachnoid hemorrhage with negative noncontrast CT local protocol dependent

›Suspected cerebral venous thrombosis alternate pathway with CT venography local protocol dependent

Ultrasound

›Bedside ultrasound adjuncts

›IVC assessment for dehydration context

›Lung ultrasound for aspiration or pulmonary edema context

›Ocular ultrasound for papilledema surrogate when concern for elevated intracranial pressure local protocol dependent

13Special Tests/spec13

EEG pathways

›Electroencephalography indications

›Persistent altered mental status without explanation

›Concern for nonconvulsive status epilepticus

›Paralysis or aphasia not improving as expected

Lumbar puncture

›CSF evaluation

›Fever with seizure and altered mental status

›Immunocompromised with seizure

›Concern for encephalitis

›Consider imaging first when focal deficit or papilledema concern

Continuous monitoring

›Monitoring beyond initial evaluation

›Continuous pulse oximetry

›Capnography when sedatives used

›Serial neuro checks with time stamps

14ECG/ecg11

Indications

›ECG role in seizure presentations

›Syncope mimic

›Toxin screening

›QT prolongation screening

›Arrhythmia triggered cerebral hypoperfusion

High risk patterns

›Dangerous findings

›QRS widening

›QTc prolongation

›Brugada pattern

›Ventricular ectopy

›High grade AV block

15Assessment/ax21

Working synthesis

›Primary problem framing

›Postictal state most likely

›Breakthrough seizure due to provocation

›Suspected status epilepticus

›Suspected nonconvulsive status epilepticus

Severity and trajectory

›Risk stratification elements

›Time since seizure ended

›Rate of mental status improvement

›Presence of recurrent seizures

›Presence of new focal deficits

›Presence of fever

Complications to exclude

›Complications

›Aspiration pneumonitis

›Rhabdomyolysis

›Traumatic injury

›Cardiac dysrhythmia

Special populations

›Higher risk cohorts

›Pregnancy or postpartum

›Anticoagulated

›Immunocompromised

›Elderly with first seizure

16Plan/plan51

First 5 minutes

›Immediate stabilization

›Airway and oxygenation

›Cardiac monitoring

›Continuous pulse oximetry

›IV access

›Capillary glucose

›Temperature

Active seizure treatment

›Convulsive seizure algorithm

›If seizure longer than 5 minutes treat as status epilepticus

›Lorazepam IV 0.1 mg per kg

›Maximum 4 mg per dose

›Repeat once after 5 minutes if ongoing

›Midazolam IM 10 mg if no IV access

›Midazolam IN 0.2 mg per kg if IN route used local protocol dependent

Second line antiseizure loading

›Urgent loading after benzodiazepine

›Levetiracetam IV 60 mg per kg

›Maximum 4500 mg

›Fosphenytoin IV 20 mg PE per kg

›Maximum 1500 mg PE

›Valproate IV 40 mg per kg

›Maximum 3000 mg

›Choice based on contraindications and local protocol dependent

Refractory status escalation

›Refractory pathway

›Intubation for airway protection when needed

›Continuous EEG when available

›Midazolam infusion local protocol dependent

›Propofol infusion local protocol dependent

›Vasopressor support when needed

Postictal agitation management

›Safety and reversible causes

›Hypoxia correction

›Hypoglycemia correction

›Pain control

›Avoid excess sedatives that obscure neuro exam when possible

›Haloperidol IM 2 mg to 5 mg for severe agitation local protocol dependent

›Olanzapine IM 5 mg to 10 mg local protocol dependent

Provocation correction

›Trigger targeted therapy

›Electrolyte repletion

›Sodium correction per hyponatremia pathway

›Magnesium sulfate IV 2 g if low or torsades risk

›Thiamine IV 100 mg for alcohol use disorder before glucose when malnourished

›Pyridoxine IV for isoniazid toxicity local protocol dependent

Diagnostics sequencing

›Testing workflow

›CT head early when high risk features present

›Infection workup when febrile

›EEG when persistent altered mental status unexplained

Reassessment loop

›Time based reassessment

›Neuro checks every 15 minutes until improving

›Vital signs every 15 minutes during sedatives

›Repeat glucose after correction

›Repeat exam after benzodiazepine effect wanes

›Escalate if no improvement within expected postictal window

17Disposition/dispo29

ICU level care

›ICU indications

›Status epilepticus

›Refractory seizures requiring infusion

›Intubation

›Persistent hypoxemia

›Severe metabolic derangement

Inpatient admission

›Admission indications

›Persistent altered mental status

›New focal neurologic deficit

›Abnormal CT or MRI

›Suspected CNS infection

›Pregnancy related seizure

›Recurrent seizures in ED

›Antiseizure medication toxicity

›Unsafe home supervision

Observation pathway

›Observation appropriate when

›Improving mental status

›No recurrent seizures

›Labs reassuring

›Imaging negative when obtained

›Reliable supervision available

Discharge criteria

›Discharge requires

›Returned to baseline mental status

›No new focal deficit

›No recurrent seizures after ED observation period local protocol dependent

›Provoking factor addressed when identified

›Antiseizure regimen reconciled

›Reliable follow up arranged

›Driving and safety counseling provided

18Discharge Instructions/di29

Copy discharge instructions

›Seizure and recovery summary

›You were seen for a seizure with a recovery period that can include confusion and sleepiness

›Most people gradually return to their usual self over hours

›Medications

›Take your seizure medicines exactly as prescribed

›If you missed doses today take the next scheduled dose unless told otherwise

›Do not stop seizure medicines suddenly

›Safety

›Do not drive until cleared by your clinician and local rules

›Avoid swimming or bathing alone

›Avoid heights and operating heavy machinery

›Triggers

›Avoid alcohol and recreational drugs

›Prioritize sleep

›Stay hydrated

›Follow up

›Follow up with your family doctor within 1 to 3 days

›Neurology follow up within 1 to 2 weeks if available

›Return to emergency immediately for

›Another seizure

›A seizure lasting more than 5 minutes

›Back to back seizures without full recovery

›New weakness

›Trouble speaking

›Severe headache

›Fever

›Neck stiffness

›Trouble breathing

›Persistent confusion not improving

19References/r18

Key guidelines and tools

›American Epilepsy Society guideline for convulsive status epilepticus 2016

›Benzodiazepines first line

›Second line antiseizure loading options

›International League Against Epilepsy definition and classification of status epilepticus 2015

›Time thresholds for treatment urgency

›Concept of ongoing seizure activity

›AAN and AES guideline on management of an unprovoked first seizure in adults 2015

›Recurrence risk discussion

›Role of EEG and imaging

›Neurocritical Care Society guideline for status epilepticus 2012

›Escalation to anesthetic infusions

›Continuous EEG use

›NICE guideline on epilepsies diagnosis and management 2022

›Follow up planning and safety counseling

›Antiseizure medication principles

›2HELPS2B score for EEG seizure risk stratification validation studies

›Use only with EEG availability

›Not a substitute for clinical judgment

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Postictal State and Seizure Recurrence ConcernAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

590 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx91

Presenting context

›Postictal and recurrence context

›Witnessed seizure description

›Unwitnessed event

›Found down

›Baseline neurocognitive function

›Return to baseline timing

OPQRST

›Onset

›Last known normal time

›Time of event

›Time last seizure ended

›Time to first purposeful response

›Provocation or palliation

›Sleep deprivation

›Missed antiseizure medications

›Alcohol withdrawal window

›Recent illness

›Fever

›Photostimulation exposure

›Hyperventilation exposure

›Quality

›Confusion

›Somnolence

›Agitation

›Aphasia

›Amnesia

›Headache

›Focal weakness

›Region or radiation

›Focal motor onset region

›Sensory aura distribution

›Headache location

›Tongue injury location

›Severity

›Persistent inability to follow commands

›Need for restraints

›Recurrent seizures in ED

›Respiratory compromise during event

›Timing

›Seizure duration estimate

›Cluster pattern

›Frequency change from baseline

›Prior postictal duration typical

Associated features

›Peri ictal and postictal features

›Tongue bite

›Urinary incontinence

›Cyanosis

›Prolonged snoring respirations

›Postictal headache

›Postictal myalgia

›Todd paralysis duration

›New focal neurologic deficit

Prior seizure history

›Epilepsy and prior events

›First lifetime seizure concern

›Known epilepsy syndrome

›Prior status epilepticus

›Typical semiology and triggers

›Prior EEG and neuroimaging results

Recent exposures and triggers

›Reversible precipitants

›Alcohol use pattern

›Recent cessation of alcohol

›Stimulants

›Cocaine

›Amphetamines

›Synthetic cannabinoids

›Medication toxicity exposure

›Bupropion exposure

›Tramadol exposure

›Isoniazid exposure

›Diphenhydramine exposure

›Organophosphate exposure

Infectious and inflammatory context

›CNS infection and inflammation context

›Fever

›Neck pain

›Rash

›Immunocompromised status

›Recent travel

›Recent antimicrobial use

Trauma and vascular context

›Head and vascular context

›Head trauma

›Anticoagulant use

›Thunderclap headache

›Persistent severe headache

›Pregnancy or postpartum

›Known aneurysm

›Known arteriovenous malformation

Pediatric and adolescent specific

›Age specific context

›Febrile seizure pattern

›Ingestions risk

›School or sports head injury

›Developmental delay baseline

›Non accidental trauma concern

02Alarm Features/alarm30

Immediate threats

›Time critical seizure syndromes

›Ongoing convulsive seizure

›Suspected nonconvulsive status epilepticus

›Recurrent seizures without return to baseline

›New persistent focal deficit

›Airway compromise

›Hypoxemia

›Aspiration

High risk vitals

›Dangerous physiology

›Systolic hypotension

›Severe hypertension with neurologic symptoms

›Fever

›Hypothermia

›Persistent hypoxemia

›Hypoventilation

High risk history triggers

›Cannot miss contexts

›First lifetime seizure with persistent altered mental status

›Pregnancy or postpartum seizure

›Immunocompromised with seizure

›Recent head trauma

›Anticoagulant or antiplatelet with head injury

›Known malignancy

›Suspected toxin ingestion

Escalation triggers

›Resuscitation activation thresholds

›Seizure longer than 5 minutes

›Second seizure without baseline recovery

›Persistent GCS less than 13 after expected postictal window

›Refractory agitation preventing assessment

›Hyperthermia with rigidity

›Cardiac arrhythmia concern

03Medications/meds27

Antiseizure regimen

›Chronic antiseizure medications

›Name and formulation

›Dose and schedule

›Last dose time

›Recent dose change

›Recent missed doses

High risk medication exposures

›Pro convulsant and interacting agents

›Bupropion

›Tramadol

›Theophylline

›Clozapine

›Lithium

›SSRIs

›TCAs

›Fluoroquinolones

›Isoniazid

Sedatives and withdrawal agents

›Withdrawal relevant agents

›Benzodiazepines

›Barbiturates

›Baclofen

›Alcohol

Anticoagulants and antiplatelets

›Bleeding risk agents

›Warfarin

›Direct oral anticoagulants

›Heparin

›Aspirin

›P2Y12 inhibitors

04Diet/diet15

Intake and metabolic risks

›Nutritional and hydration status

›Poor oral intake

›Vomiting

›Diarrhea

›Dehydration risk

›Fasting

›Keto diet exposure

Caffeine and stimulants

›Sympathomimetic exposures

›Energy drinks

›High caffeine intake

›Pre workout supplements

Alcohol exposure

›Alcohol pattern

›Heavy use

›Last drink time

›Withdrawal risk window

05Review of Systems/ros27

Neurologic

›Neuro symptoms

›Headache

›Neck stiffness

›Photophobia

›Persistent confusion

›Focal weakness

›Speech disturbance

›Visual loss

›New gait instability

Infectious and inflammatory

›Infection symptoms

›Fever

›Chills

›Rash

›Recent URI symptoms

›Dysuria

Cardiorespiratory

›Cardiopulmonary symptoms

›Chest pain

›Palpitations

›Dyspnea

›Syncope prodrome

Toxicologic and endocrine

›Metabolic and toxin symptoms

›Polyuria

›Polydipsia

›Weight loss

›Tremor

›Diaphoresis

›Heat exposure

06Collateral History and Family History/chafh14

Collateral sources

›Witness and collateral reliability

›EMS report

›Family report

›Video of event

›Baseline mental status confirmation

Family history

›Seizure and sudden death history

›Epilepsy in first degree relatives

›Sudden unexplained death

›Channelopathy history

›Early stroke history

Social support

›Supervision and safety reliability

›Responsible adult available

›Ability to observe for recurrence

›Ability to obtain medications

07Risk Factors/rf24

Structural and vascular

›Brain lesion risk

›Prior stroke

›Intracranial hemorrhage history

›Brain tumor history

›AVM or aneurysm history

›Recent head trauma

Metabolic and systemic

›Physiologic provocation risks

›Diabetes mellitus

›Chronic kidney disease

›Chronic liver disease

›Electrolyte disorders history

›Poor sleep

Toxicologic

›Exposure risks

›Substance use disorder

›Recent medication overdose risk

›Occupational toxin exposure

Pregnancy related

›Obstetric risks

›Pregnancy

›Postpartum within 6 weeks

›Preeclampsia history

Pediatric and adolescent

›Age related risks

›Febrile illness

›Ingestions

›Non accidental trauma risk

08Differential Diagnosis/ddx66

Life threatening

›Immediate life threats

›Status epilepticus

›Persistent altered mental status

›Recurrent seizures without baseline recovery

›Nonconvulsive status epilepticus

›Persistent confusion

›Subtle motor automatisms

›Hypoglycemia

›Diaphoresis

›Low point of care glucose

›CNS infection

›Fever

›Neck stiffness

›Intracranial hemorrhage

›Head trauma

›Anticoagulants

›Acute ischemic stroke with seizure

›New focal deficit

›Aphasia

›Subarachnoid hemorrhage

›Thunderclap headache

›Meningismus

›Eclampsia

›Pregnancy or postpartum

›Severe hypertension

›Toxic ingestion

›QRS widening on ECG

›Anticholinergic toxidrome

Common

›Common causes

›Postictal state

›Typical semiology

›Gradual improvement over time

›Breakthrough seizure from missed doses

›Nonadherence

›Vomiting or malabsorption

›Alcohol withdrawal seizure

›Tremor

›Autonomic hyperactivity

›Sleep deprivation provoked seizure

›Recent short sleep

›Shift work

›Infection provoked seizure

›Fever

›Systemic illness

Less common

›Less common and mimics

›Psychogenic nonepileptic event

›Asynchronous movements

›Eye closure with resistance

›Syncope with convulsive movements

›Presyncope prodrome

›Rapid recovery without postictal confusion

›Hyponatremia

›Diuretic use

›Polydipsia

›Hyperglycemic hyperosmolar state

›Marked dehydration

›Very high serum osmolality

›Medication toxicity

›Lithium

›Theophylline

›Encephalitis

›Behavioral change

›New seizures

›Cerebral venous thrombosis

›Pregnancy or postpartum

›Persistent headache

09Past Medical History/pmh20

Neurologic history

›Epilepsy and neurologic comorbidity

›Epilepsy diagnosis

›Prior EEG abnormalities

›Prior neuroimaging abnormalities

›Prior neurosurgery

›Prior CNS infection

Medical comorbidities

›Systemic conditions

›Diabetes

›Renal disease

›Hepatic disease

›Heart disease

›Substance use disorder

Prior ED utilization

›Prior acute care patterns

›Recent ED visits for seizures

›Prior ICU admissions for status epilepticus

›Prior intubation for seizures

Baseline function

›Baseline status

›Baseline mental status

›Baseline mobility

›Caregiver dependence

10Physical Exam/exam43

General and vitals

›Global assessment

›Airway patency

›Work of breathing

›Oxygen saturation trend

›Temperature

›Persistent tachycardia

Neurologic

›Neuro exam focus

›Level of consciousness

›Orientation

›Command following

›Speech

›Pupils

›Extraocular movements

›Facial symmetry

›Motor strength

›Pronator drift

›Sensory asymmetry

›Reflexes

›Coordination

›Gait when safe

Postictal patterns

›Features supporting postictal state

›Gradual improvement

›Sleepiness

›Headache

›Todd paralysis resolving

Trauma and toxidrome screen

›Injury and tox findings

›Scalp hematoma

›Signs of basilar skull fracture

›Tongue lacerations

›Shoulder dislocation

›Track marks

›Anticholinergic signs

›Diaphoresis

›Hyperreflexia

Cardiopulmonary

›Heart and lungs

›Arrhythmia signs

›Heart murmur

›Aspiration findings

›Wheeze

Meningeal signs

›Meningitis and encephalitis clues

›Nuchal rigidity

›Photophobia

›Rash

11Lab Studies/labs37

Point of care testing

›Immediate bedside tests

›Capillary glucose

›Pregnancy test when relevant

›Temperature recheck trend

Core serum studies

›High yield screening labs

›Sodium

›Potassium

›Calcium

›Magnesium

›Creatinine

›Urea

›AST

›ALT

›Bilirubin

›CBC

Acid base and hypoxemia

›Respiratory and metabolic physiology

›Venous blood gas

›Arterial blood gas when ventilatory failure concern

›Lactate trend

Toxicology and levels

›Exposure directed studies

›Ethanol level when relevant

›Acetaminophen level when ingestion possible

›Salicylate level when ingestion possible

›Urine drug screen local protocol dependent

Antiseizure medication levels

›Level guided management

›Phenytoin level

›Valproate level

›Carbamazepine level

›Phenobarbital level

Infection evaluation

›Systemic infection evaluation

›Blood cultures when febrile and unstable

›CRP local protocol dependent

›Procalcitonin local protocol dependent

Interpretation pitfalls

›Common traps

›Lactate elevation after generalized tonic clonic seizure

›Leukocytosis after seizure

›Mild metabolic acidosis after seizure

12Imaging/img24

Scoring Systems

›Risk and severity tools

›Status Epilepticus Severity Score

›Limited validation across settings

›2HELPS2B for EEG seizure risk

›Use only with EEG availability

MRI

›MRI brain considerations

›First unprovoked seizure outpatient pathway when stable

›Concern for encephalitis

›Concern for tumor

›Concern for cortical dysplasia

›CT head noncontrast

›New focal deficit

›Persistent altered mental status

›Head trauma

›Anticoagulant use

›Immunocompromised status

›Concern for intracranial hemorrhage

›CT angiography head and neck

›Suspected subarachnoid hemorrhage with negative noncontrast CT local protocol dependent

›Suspected cerebral venous thrombosis alternate pathway with CT venography local protocol dependent

Ultrasound

›Bedside ultrasound adjuncts

›IVC assessment for dehydration context

›Lung ultrasound for aspiration or pulmonary edema context

›Ocular ultrasound for papilledema surrogate when concern for elevated intracranial pressure local protocol dependent

13Special Tests/spec13

EEG pathways

›Electroencephalography indications

›Persistent altered mental status without explanation

›Concern for nonconvulsive status epilepticus

›Paralysis or aphasia not improving as expected

Lumbar puncture

›CSF evaluation

›Fever with seizure and altered mental status

›Immunocompromised with seizure

›Concern for encephalitis

›Consider imaging first when focal deficit or papilledema concern

Continuous monitoring

›Monitoring beyond initial evaluation

›Continuous pulse oximetry

›Capnography when sedatives used

›Serial neuro checks with time stamps

14ECG/ecg11

Indications

›ECG role in seizure presentations

›Syncope mimic

›Toxin screening

›QT prolongation screening

›Arrhythmia triggered cerebral hypoperfusion

High risk patterns

›Dangerous findings

›QRS widening

›QTc prolongation

›Brugada pattern

›Ventricular ectopy

›High grade AV block

15Assessment/ax21

Working synthesis

›Primary problem framing

›Postictal state most likely

›Breakthrough seizure due to provocation

›Suspected status epilepticus

›Suspected nonconvulsive status epilepticus

Severity and trajectory

›Risk stratification elements

›Time since seizure ended

›Rate of mental status improvement

›Presence of recurrent seizures

›Presence of new focal deficits

›Presence of fever

Complications to exclude

›Complications

›Aspiration pneumonitis

›Rhabdomyolysis

›Traumatic injury

›Cardiac dysrhythmia

Special populations

›Higher risk cohorts

›Pregnancy or postpartum

›Anticoagulated

›Immunocompromised

›Elderly with first seizure

16Plan/plan51

First 5 minutes

›Immediate stabilization

›Airway and oxygenation

›Cardiac monitoring

›Continuous pulse oximetry

›IV access

›Capillary glucose

›Temperature

Active seizure treatment

›Convulsive seizure algorithm

›If seizure longer than 5 minutes treat as status epilepticus

›Lorazepam IV 0.1 mg per kg

›Maximum 4 mg per dose

›Repeat once after 5 minutes if ongoing

›Midazolam IM 10 mg if no IV access

›Midazolam IN 0.2 mg per kg if IN route used local protocol dependent

Second line antiseizure loading

›Urgent loading after benzodiazepine

›Levetiracetam IV 60 mg per kg

›Maximum 4500 mg

›Fosphenytoin IV 20 mg PE per kg

›Maximum 1500 mg PE

›Valproate IV 40 mg per kg

›Maximum 3000 mg

›Choice based on contraindications and local protocol dependent

Refractory status escalation

›Refractory pathway

›Intubation for airway protection when needed

›Continuous EEG when available

›Midazolam infusion local protocol dependent

›Propofol infusion local protocol dependent

›Vasopressor support when needed

Postictal agitation management

›Safety and reversible causes

›Hypoxia correction

›Hypoglycemia correction

›Pain control

›Avoid excess sedatives that obscure neuro exam when possible

›Haloperidol IM 2 mg to 5 mg for severe agitation local protocol dependent

›Olanzapine IM 5 mg to 10 mg local protocol dependent

Provocation correction

›Trigger targeted therapy

›Electrolyte repletion

›Sodium correction per hyponatremia pathway

›Magnesium sulfate IV 2 g if low or torsades risk

›Thiamine IV 100 mg for alcohol use disorder before glucose when malnourished

›Pyridoxine IV for isoniazid toxicity local protocol dependent

Diagnostics sequencing

›Testing workflow

›CT head early when high risk features present

›Infection workup when febrile

›EEG when persistent altered mental status unexplained

Reassessment loop

›Time based reassessment

›Neuro checks every 15 minutes until improving

›Vital signs every 15 minutes during sedatives

›Repeat glucose after correction

›Repeat exam after benzodiazepine effect wanes

›Escalate if no improvement within expected postictal window

17Disposition/dispo29

ICU level care

›ICU indications

›Status epilepticus

›Refractory seizures requiring infusion

›Intubation

›Persistent hypoxemia

›Severe metabolic derangement

Inpatient admission

›Admission indications

›Persistent altered mental status

›New focal neurologic deficit

›Abnormal CT or MRI

›Suspected CNS infection

›Pregnancy related seizure

›Recurrent seizures in ED

›Antiseizure medication toxicity

›Unsafe home supervision

Observation pathway

›Observation appropriate when

›Improving mental status

›No recurrent seizures

›Labs reassuring

›Imaging negative when obtained

›Reliable supervision available

Discharge criteria

›Discharge requires

›Returned to baseline mental status

›No new focal deficit

›No recurrent seizures after ED observation period local protocol dependent

›Provoking factor addressed when identified

›Antiseizure regimen reconciled

›Reliable follow up arranged

›Driving and safety counseling provided

18Discharge Instructions/di29

Copy discharge instructions

›Seizure and recovery summary

›You were seen for a seizure with a recovery period that can include confusion and sleepiness

›Most people gradually return to their usual self over hours

›Medications

›Take your seizure medicines exactly as prescribed

›If you missed doses today take the next scheduled dose unless told otherwise

›Do not stop seizure medicines suddenly

›Safety

›Do not drive until cleared by your clinician and local rules

›Avoid swimming or bathing alone

›Avoid heights and operating heavy machinery

›Triggers

›Avoid alcohol and recreational drugs

›Prioritize sleep

›Stay hydrated

›Follow up

›Follow up with your family doctor within 1 to 3 days

›Neurology follow up within 1 to 2 weeks if available

›Return to emergency immediately for

›Another seizure

›A seizure lasting more than 5 minutes

›Back to back seizures without full recovery

›New weakness

›Trouble speaking

›Severe headache

›Fever

›Neck stiffness

›Trouble breathing

›Persistent confusion not improving

19References/r18

Key guidelines and tools

›American Epilepsy Society guideline for convulsive status epilepticus 2016

›Benzodiazepines first line

›Second line antiseizure loading options

›International League Against Epilepsy definition and classification of status epilepticus 2015

›Time thresholds for treatment urgency

›Concept of ongoing seizure activity

›AAN and AES guideline on management of an unprovoked first seizure in adults 2015

›Recurrence risk discussion

›Role of EEG and imaging

›Neurocritical Care Society guideline for status epilepticus 2012

›Escalation to anesthetic infusions

›Continuous EEG use

›NICE guideline on epilepsies diagnosis and management 2022

›Follow up planning and safety counseling

›Antiseizure medication principles

›2HELPS2B score for EEG seizure risk stratification validation studies

›Use only with EEG availability

›Not a substitute for clinical judgment

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.