Browse categories and answer follow-up questions to refine your symptom profile.
History
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
Alarm Features
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
Medications
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
Diet
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
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.