Because many patients with nonfocal symptoms have abnormal neuroimaging, the

AmericanCollegeofEmergencyPhysiciansrecommendsheadCTforallpatientswho
presenttotheemergencydepartmentwithafirstseizure. 7,11However,stablepatientswho
have returned to baseline neurologic status may be discharged and scheduled for
outpatientneuroimagingiffollowupcanbeensured.11
Amongpatientswhodonotpresentto(orwhoarenotevaluatedin)theemergency
department,outpatientneuroimagingafterafirstnonfebrileseizureisrecommendedfor
adultsbecauseofitssubstantialyieldofdetectingabnormalitiesthatchangemanagement
(10percent).26Inchildren,however,itisrecommendedonlyinthoseyoungerthanone
yearandinthosewithcognitiveormotordevelopmentaldelay,unexplainedneurologic
abnormalities,ahistoryoffocalseizures,orfindingsonelectroencephalography(EEG)
thatareincompatiblewithbenignpartialepilepsyofchildhoodorprimarygeneralized
epilepsy.27 Magnetic resonance imaging is generally the preferred imaging modality
becauseitismoresensitivethanCTatdetectingintrinsicbraintumors,stroke,focal
cortical dysplasia, mesial temporal sclerosis, vascular malformations, and cerebral
dysgenesis.2629 EEG and magnetic resonance imaging, combined with a clinical
evaluation,mayadditionallyleadtothediagnosisofanelectroclinicalsyndrome.5,17,29
LABORATORYTESTS
Laboratoryinvestigationsshouldbetailoredtotheindividualpatientanddrivenprimarily
by findings from the history and physical examination.26,27,30 For example, a serum
glucoselevelshouldbeorderedforapatientwithdiabetesmellitus,andacomprehensive
metabolic panel and ammonia level should be ordered for a patient with cirrhosis.
Because an underlying seizure focus may be unmasked by the physiologic stress of
pregnancy, a pregnancy test should be ordered for women of childbearing age. 31 To
distinguishseizuresfrompsychogenicnonepilepticevents,anelevatedserumprolactin
level(atleasttwotimesthebaselinevalue)measured10to20minutesafteraneventis
moderatelysensitiveandhighlyspecificforgeneralizedtonicclonicseizuresandfocal
seizureswithalteredconsciousness.32Forhealthyadultpatientswhohaverecoveredand
returned to their baseline neurologic status, the American College of Emergency
Physicians recommends checkingserumglucoseandsodiumlevelsbecausetheseare
commondisturbancesthatmaybepresentintheabsenceofanyotherfindings.11,31
LUMBARPUNCTURE
Lumbarpunctureisnotroutinelyindicatedafterafirstseizure,butshouldbeperformed
ifthereisconcernaboutcentralnervoussysteminfectionafterobtainingnegativehead
CTresults.26,27Infectionshouldbe