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Seizures/epilepsy

ADULT

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

  • Refer to Healthpathways or local guidelines
  • Ensure compliance, consider drug levels if non-compliance is suspected
  • Optimise current drug therapy/consider increasing dose if already on medication
  • Exclude drug interactions e.g. concurrent cytochrome inducers, binding agents
  • Reconsider diagnosis if no response to medication
  • Treat any inter-current infections and co-morbidities
  • Address any lifestyle issues e.g. adequate sleep, stress, alcohol, recreational drugs

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • New diagnosis of epilepsy (confirmed or highly likely)
    • First epileptic seizure (as convulsive syncope is a common mimic, may be seen by general medicine prior to neurology, depending on local pathways)
    • Frequent seizure activity with current anticonvulsants use
    • High seizure frequency without antiepileptic therapy
    • Pregnancy in a patient with known epilepsy
  • Category 2
    (appointment within 90 calendar days)
    • Poorly controlled epilepsy (e.g. increased frequency of seizures, change in seizure activity) in patient with good adherence to medical treatment. (This may be categorised as Cat 1 depending on severity)
    • Suspected non-epileptic attacks* 

    *Suspected non-epileptic seizures should be triaged according to the social and medical impact of their epileptic-seizure counterparts rather than based on the (suspected) cause

  • Category 3
    (appointment within 365 calendar days)

    • Chronic epilepsy without any concerning features.  Concerning features include:
      • focal deficit post-ictally
      • seizure associated with recent trauma
      • persistent severe headache > 1 hour post-ictally
      • seizure with fever
    • Epilepsy advice and management plan including driving recommendations and decreasing anti-epileptic medication

     


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

  • ELFT FBC
  • History of seizures
  • Medication history, including non-prescription medications, herbs and supplements
  • Management history of epilepsy (including previous medication, dosage, efficacy, side effects)

3. Additional referral information Useful for processing the referral

  • EEG results
  • Neuroimaging results
  • Drug level results (if available)
  • Family history
  • Drug and alcohol history
  • Sleep studies (if available)
  • HIV syphilis (if available)

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.