What initial assessments should I perform for a patient presenting with a suspected first seizure?

Initial assessments for a patient presenting with a suspected first seizure include:

• Take a detailed history from the patient and, if possible, from eyewitnesses or carers, including a description of the seizure event and any video footage available to inform the assessment.
• Perform a thorough physical examination.
• Conduct a 12-lead electrocardiogram (ECG) to identify any cardiac conditions that could mimic seizures.
• Consider metabolic causes such as hypoglycaemia and assess accordingly.
• If the history and examination suggest an epileptic seizure, consider arranging a routine electroencephalogram (EEG) while awake, ideally within 72 hours of the seizure, to support diagnosis and help classify seizure type or epilepsy syndrome.
• Discuss with the patient and carers the benefits and risks of EEG provoking maneuvers such as hyperventilation and photic stimulation, and include these if agreed.
• Offer brain neuroimaging, preferably MRI, if a structural cause is suspected based on clinical findings.
• Provide the patient and their family or carers with information on recognising further seizures, first aid, safety advice, and who to contact if another seizure occurs while awaiting specialist assessment.

These assessments should be followed by urgent referral to a specialist with expertise in first seizure assessment and epilepsy diagnosis for further evaluation and management.

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