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Seizures/epilepsy

PAEDIATRIC

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


Adult

Stroke/transient ischaemic attack (TIA)

  • Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
  • New acute symptoms

Progressive loss of neurological function

  • Acute onset severe:
    • ataxia
    • vertigo
    • visual loss
  • Acute severe exacerbation of known MS

Seizures/epilepsy

  • Status epilepticus/epilepsy with concerning features:
    • first seizure
    • focal deficit post-ictally
    • seizure associated with recent trauma
    • persistent severe headache > 1 hour post-ictally
    • seizure with fever

Headache/migraine

  • Headache with concerning features:
    • sudden onset/thunderclap headache
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • first severe headache age > 50 years
    • severe headache associated with recent head trauma
    • recent onset headaches in young obese females
    • headaches with papilledema
    • >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected

Movement disorders

  • Ocular

Other referrals to emergency

  • Altered level of consciousness
  • Bilateral limb weakness with or without bladder and/or bowel dysfunction
  • Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
  • Delirium/sudden onset confusion with or without fever

 

Paediatric

Seizures/epilepsy

  • New onset seizures that require emergency care/advice
  • Status epilepticus (convulsive or non-convulsive)
  • Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
  • New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
  • Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
  • High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
  • Neonate / infant (<12-month-old) with epileptic seizure onset

Headaches/migraine

  • Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
  • Headaches that wake at night or headaches immediately on wakening
  • New severe headaches
  • Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
  • Focal neurological features
  • Associated with significant persisting change of personality or cognitive ability or deterioration in school performance

Functional neurological symptoms

  • The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition

Movement disorder

  • Abrupt onset or deterioration of a movement disorder
  • Acute onset of ataxia / chorea
  • Impairment of function i.e. walking, attend school

Hypotonic infant

  • Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
  • Feeding difficulties with weight loss

Gait abnormality, isolated motor delay or focal weakness

  • Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
  • Acute onset focal weakness (suspected stroke – call 000)
  • Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
  • Feeding or swallowing difficulties
  • Acute foot drop or acute onset focal neuropathy

Stroke

  • Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)

Other neurological conditions

  • Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
  • Acute encephalopathy, acute confusional state, altered level of consciousness
  • Direct referral to Epileptologist accepted for:
    • focal epilepsy for surgical evaluation,
    • focal epilepsy without established aetiology – for advanced aetiology diagnostic support,
    • specific aetiologies – focal cortical dysplasia, Sturge Weber, Rasmussen syndrome, Tuberous Sclerosis (if infant is < 2 years, please call to discuss) or
    • drug resistant epilepsy for advanced aetiology diagnostic support or treatment (e.g. palliative surgery)


For specific aetiologies, patients may be seen even if they do not have epilepsy, for counselling around future risk/management. At the discretion of the Epileptologist triaging the referral, the patient may be re-directed to inpatient assessment for first attendance rather than outpatient assessment.

  • Referral for ketogenic diet (Ketogenic Diet Clinic) is accepted only from a Metabolic Physician or Paediatric Neurologist
  • Referral for VNS therapy (VNS Therapy Clinic) is accepted only from a Paediatric Neurologist
  • MRI using a dedicated high-resolution epilepsy protocol (this may not be done as part of ‘MRI brain’ protocols), is the imaging of choice for patients with epilepsy. A CT is not sufficiently helpful in diagnosing epilepsy aetiologies.  For children who require anaesthetic, please discuss appropriate location for MRI in advance, to ensure the optimal scan is obtained.
  • EEG investigations may be requested separately (refer to referral resource for EEG, referrals are accepted from Emergency Departments, Inpatient Units and Paediatricians)
  • A change in patient circumstance (such as condition deteriorating) may affect the urgency categorisation and should be communicated as soon as possible.
  • Referral from a health practitioner other than a General Paediatrician may be accepted if there is limited access to public Paediatric services in the patients’ local area
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment

Clinical resources

Patient resources

 

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Epilepsy onset </=2 years
    • Referral from General Paediatrician with patient has uncontrolled current seizures/events > 1 per month
      • to confirm a diagnosis of epilepsy
      • to exclude epilepsy imitators
      • for diagnostic assessment of epilepsy aetiology
      • for a patient with drug resistance (failing second appropriate AED)
    • Valproate deemed essential in a female of child-bearing potential with uncontrolled tonic-clonic seizures >1 per month
    • Focal epilepsy (cause known or unknown) with seizure frequency > 1/month, especially if high seizure burden (>5 seizures) before first AED
    • Epilepsy onset in a patient with developmental/cognitive/psychiatric comorbidity without known cause (aetiologies include some disorders requiring early specific therapy, e.g. CLN, advanced genomic testing is available through neurology services) (call Paediatric Neurologist on call, and refer)
    • Specific syndromes suspected e.g. Epilepsy with Myoclonic-Atonic Seizures, Dravet Syndrome, Landau Kleffner Syndrome, Lennox Gastaut Syndrome, Epileptic Encephalopathy with Continuous Spike-And-Wave in Sleep, Progressive Myoclonus Epilepsy.
    • Infant < 2 years of age at risk of or diagnosis of Tuberous Sclerosis (referral before onset of seizures/antenatal referral preferred – if antenatal or  infant < 2 years, please call to discuss)
    • Specific aetiology with epilepsy e.g. Sturge Weber, Rasmussen, unilateral structural brain malformation (suspected or confirmed), hypothalamic hamartoma
    • At risk of glucose transporter disorder (any of: early onset absence seizures <4 years, episodes of altered tone/floppiness/weakness, progressive microcephaly, absence seizures with abnormal EEG background) (call Paediatric Neurologist on call, and refer)

     

  • Category 2
    (appointment within 90 calendar days)
    • Referral from General Paediatrician with patient has uncontrolled current seizures/events < 1 per month
      • to confirm a diagnosis of epilepsy
      • to exclude epilepsy imitators
      • for diagnostic assessment of epilepsy aetiology
      • for a patient with drug resistance (failing second appropriate AED)
    • Valproate deemed essential in a female of child-bearing potential with uncontrolled seizures and tonic-clonic seizures <1 per month
    • Focal epilepsy with seizure frequency < 1/month
    • At risk of epilepsy for which specific treatment/referral path may be indicated (to counsel course of action if seizures emerge) e.g. focal cortical dysplasia on MRI but not yet experiencing seizures

     

  • Category 3
    (appointment within 365 calendar days)
    • No category 3 criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Detailed seizure description (sequence of symptoms and signs), duration, frequency, date / age of onset and severity factors (e.g. loss of consciousness, loss of awareness, cyanosis, injuries, frequency of use of emergency services/medication)
  • Details of current and past medications used to control epilepsy, if any
  • Current developmental status if pre-school (age appropriate, some delay, significant delay, regression), academic/learning status (if school age, in mainstream/mainstream with support/special education)
  • Neurological examination

3. Additional referral information Useful for processing the referral

Highly desirable information - may change triage category

  • Family history of epilepsy, febrile seizures, learning difficulty, developmental impairments, mental health disorders, movement disorders (especially if exercise induced)
  • All previous EEG, MRI, pathology and genetic results/reports
  • If neuroimaging has been done, arrange image transfer to PACS at the hospital the patient is being referred to, with the imaging reports. If electronic imaging transfer is not available, then a CD of the neuroimaging and report should be sent to the neurologist named in the referral. See ‘other useful information’ below.
  • Where possible include eye-witness accounts, and request videos of events be available for consultation

Desirable information- will assist at consultation.

  • Pregnancy/birth history
  • Past medical/surgical history
  • Immunisation history
  • Medication history
  • Development and learning history, including any established diagnoses e.g. ADHD, ASD
  • Other relevant physical examination findings e.g. CNS, birth marks or dysmorphology
  • Height/weight/head circumference and growth charts with prior measurements if available.
  • Significant psychosocial risk factors (especially parents mental health, family violence, housing and financial stress, department of child safety involvement)

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.