FOTEK First Fit Guidelines - Medical Assessment Guide (EN)

GHNHSFT ED guidelines June 2014 Dr V Stacey First Fit ‘A first fit has enormous consequences – do not diagnose without good evidence.’ Criteria: Patient who has had short, self-limiting generalized fit. There is no history of head injury or fever. The examination is normal. The basic investigations are normal. No other diagnosis has been considered, e.g. meningitis, cardiac arrhythmia. The patient has fully recovered, feels well and there is someone at home with him/her. History: Full history from patient and if possible, from a witness. Type of fit – generalised or focal e.g.

tonic clonic seizure, complex partial seizure Ask the patient about symptoms of seizure, syncope, TIA, migraine, vertigo and movement disorder. If, there is a history of the patient being unwell prior to the fit, e.g. fever or head injury then this should not be considered a simple fit. Past medical history of previous seizure, febrile fits, birth trauma, meningitis, head injury and stroke. (also be wary of non epileptic attacks) Family history of seizures. Possible precipitants, e.g. major stressors, alcohol or alcohol withdrawal, drugs, sleep deprivation and flashing lights. Are they or have they been under a Consultant with similar episodes Examination:

Base line observation (Temperature, pulse, BP, Sats, GCS). Chest, cardiovascular and abdomen. Complete neurological examination, including cranial nerves and fundoscopy. Musculoskeletal (in case the patient was injured during the fit). Investigations: FBC, U&E, LFTs, Ca, Glucose. CXR (only if there is concern about aspiration, or malignancy). ECG – rate, rhythm, axis, fascicular blocks, measure QTc (prolonged QT predispose to VT or torsades de pointes, which may be the cause of the fit). Indications for CT scan: New focal deficit. Persistent altered mental status. Fever or persistent headache. Recent head trauma. History of cancer or HIV. Focal or partial onset seizure.

Anticoagulation or bleeding diathesis. Past history of stroke or TIA.

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GHNHSFT ED guidelines June 2014 Dr V Stacey Follow-up and discharge: Pending a definitive specialist diagnosis, use the term ‘seizure’ to avoid the emotive label of epilepsy. Referral to Epilepsy Specialist Nurse (use referral form available on patient first). Clear information regarding the referral process. Advise the patient that the Specialist Nurse should contact them by post usually within 7-10 days to arrange a follow up outpatient appointment to look at diagnosis.

Advice not to drive, until they have contacted the DVLA and a decision by them has been made Works and hobbies – all dangerous activities such as working at height or with machinery, or rock climbing should be avoided, but cycling and swimming, provided not alone, are allowed. (need to consider level of risk with activity to ensure safety) Give the patient a copy of the ‘first fit’ advice sheet which can be printed off patient first. This protocol should be used for all patients 16 years old and over presenting with a first fit (fulfilling above criteria).

It should also be used where presentation may be considered as a new recurrence (known epileptic, who has not had a seizure for approximately 18 months – 2 years).

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