How should I approach the initial management of a patient presenting with their first seizure in primary care?

Initial management of a patient presenting with their first seizure in primary care involves the following steps:

• Ensure immediate safety during the seizure: Note the time and protect the patient from injury by cushioning their head, removing harmful objects, and not restraining them or putting anything in their mouth. After the seizure stops, check their airway, place them in the recovery position, and observe until fully recovered. Examine for and manage any injuries ¹.
• Call emergency services (999) for hospital admission if: It is their first seizure; the seizure lasts more than 5 minutes; seizures recur shortly after the first; the person is injured or has breathing difficulties; or they are difficult to wake ¹.
• Provide first aid advice and safety information: Advise the patient and their family/carers on how to recognize and manage further seizures, including first aid measures and when to call an ambulance ¹,².
• Advise on lifestyle and safety precautions: Recommend stopping driving, avoiding potentially dangerous work or leisure activities, and being mindful of safety at home until specialist assessment is completed ¹.
• Record detailed seizure history: Take a detailed history including eyewitness accounts or video footage if possible, and perform a physical examination ².
• Urgently refer the patient to a specialist: Refer adults to a clinician with expertise in first seizures and epilepsy diagnosis, and children to a paediatrician with relevant expertise. The referral should be urgent, aiming for assessment within two weeks ¹,².
• Advise the patient to contact their GP if further seizures occur while awaiting specialist review: Urgent specialist advice should be sought if recurrent episodes occur ¹.
• Consider initial investigations: While usually arranged by specialists, an ECG may be performed in primary care to exclude cardiac causes mimicking seizures ².

Summary: In primary care, focus on immediate safety and first aid, identify when emergency admission is needed, provide safety and lifestyle advice, take a detailed history, and urgently refer for specialist assessment to confirm diagnosis and guide further management ¹,².