Neurology
Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures

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Abstract

This clinical policy focuses on critical issues in the evaluation and management of adult patients with seizures. The medical literature was reviewed for articles that pertained to the critical questions posed. Subcommittee members and expert peer reviewers also supplied articles with direct bearing on this policy. This clinical policy focuses on 6 critical questions:

  • I

    What laboratory tests are indicated in the otherwise healthy adult patient with a new-onset seizure who has returned to a baseline normal neurologic status?

  • II

    Which new-onset seizure patients who have returned to a normal baseline require a head computed tomography (CT) scan in the emergency department (ED)?

  • III

    Which new-onset seizure patients who have returned to normal baseline need to be admitted to the hospital and/or started on an antiepileptic drug?

  • IV

    What are effective phenytoin or fosphenytoin dosing strategies for preventing seizure recurrence in patients who present to the ED after having had a seizure with a subtherapeutic serum phenytoin level?

  • V

    What agent(s) should be administered to a patient in status epilepticus who continues to seize after having received benzodiazepine and phenytoin?

  • VI

    When should electroencephalographic (EEG) testing be performed in the ED?

Recommendations for patient management are provided for each 1 of these topics on the basis of strength of evidence (Level A, B, or C). Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; and Level C recommendations represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on consensus of the members of the Clinical Policies Committee. This clinical policy is intended for physicians working in hospital-based EDs.

Introduction

Epilepsy is defined as recurrent unprovoked seizures. There are an estimated 2.5 million patients with epilepsy in the United States, based on a prevalence of about 6.6 per 1,000 Americans.1 Up to 28% of all epilepsy patients require treatment in emergency departments (EDs) annually.2 Patients with seizures or presenting complaints related to seizures represent approximately 1% to 2% of all ED visits in the United States.3 An estimated 2% to 5% of the population will have at least 1 nonfebrile seizure during their lifetime.1 In addition to patients who have an established seizure diagnosis, another 150,000 patients are diagnosed with a seizure each year, most often in the ED.4

A seizure can be the result of an acute process, in which case it is referred to as an “acute symptomatic seizure,” or it can result from a past intracranial insult such as stroke, trauma, or anoxia, in which case it is referred to as a “remote symptomatic seizure.” Responsibilities of the emergency physician in evaluating and treating patients include providing stabilization and interventions to stop the seizure, preventing seizure-related complications, identifying life-threatening processes for which a seizure may be a symptom (eg, electrolyte abnormalities, intracranial hemorrhage, meningitis), determining an appropriate and timely disposition (eg, hospital admission or outpatient follow-up), and minimizing future seizure-related morbidity and mortality.

Status epilepticus is a life-threatening form of seizure. Generalized tonic-clonic status epilepticus occurs in 50,000 to 150,000 patients per year in the United States and most commonly occurs at the extremes of age.5 Between 5% to 17% of patients will have a seizure while in the ED, and up to 7% of patients in the ED will have status epilepticus. The reported mortality rate for patients in status epilepticus ranges from 5% to 22% and has been reported to be as high as 65% in those patients refractory to first-line therapies.5, 6, 7, 8

Despite its frequency, there is no universally accepted definition of status epilepticus. According to the World Health Organization, status epilepticus is “a condition characterized by an epileptic seizure that is sufficiently prolonged or repeated at sufficiently brief intervals so as to produce an unvarying and enduring epileptic condition.”9 Status epilepticus has traditionally been defined as at least 30 minutes of persistent seizures or a series of recurrent seizures without complete return to full consciousness between the seizures. Some authors have proposed shortening the time criteria for diagnosing status epilepticus from 30 minutes to 5 minutes.7 Even when properly treated, patients with status epilepticus can have serious morbidity and mortality.10 Status epilepticus is more easily recognized when it is convulsive. To diagnose nonconvulsive status epilepticus (ie, complex partial status and absence status) and subtle convulsive status epilepticus (often the terminal stage of convulsive status), emergency physicians need to maintain a high index of suspicion.11

This policy is a scheduled revision of the American College of Emergency Physicians (ACEP) seizure clinical policy.12 This policy is not intended to be a complete manual on the evaluation and management of adult patients with seizures, but rather a focused look at critical issues that have particular relevance to the practice of emergency medicine. In an attempt to maximize the usefulness of this policy, this revision is organized into “critical questions” that were determined by the committee members to represent some of the most important and controversial issues related to the evaluation and management of adult patients who present to the ED with a seizure or a seizure-related complaint. It is the goal of the Clinical Policies Committee to provide an evidence-based recommendation when the medical literature provides enough quality information to answer a “critical question.” When the medical literature does not contain enough quality information to answer a “critical question,” the members of the Clinical Policies Committee believe that it is equally important to alert emergency physicians to this fact.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP clearly recognizes the importance of the individual clinician's judgment. Rather, they define for the clinician those strategies for which medical literature exists to provide strong support for their utility in answering the crucial questions addressed in this policy.

Section snippets

Methodology

This clinical policy was created after careful review and critical analysis of the medical literature. All articles were graded by at least 2 subcommittee members for strength of evidence. The medical literature (1960 to 2002) was reviewed for articles that pertained to each critical question posed. Subcommittee members and expert peer reviewers also supplied articles with direct bearing on this policy.

The reasons for developing clinical policies in emergency medicine and the approaches used in

What laboratory tests are indicated in the otherwise healthy adult patient with a new-onset seizure who has returned to a baseline normal neurologic status?

When confronted with an otherwise healthy adult patient who has had a first-time seizure, the emergency physician must determine if the seizure was the result of an acute event that requires immediate attention. The decision of which patients with a new-onset seizure need laboratory testing is determined by the information gathered through a careful history and physical examination. Patients with a first-time seizure that is suspected to be the result of concurrent alcohol use or alcohol

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    Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.

    This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Seizures. For a complete listing of subcommittee and committee members, please see page 614.

    Approved by the ACEP Board of Directors January 16, 2004.

    This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Seizures.

    Members of the Clinical Policies Subcommittee on Seizures included:

    Andy S. Jagoda, MD, Co-Chairman

    Edwin K. Kuffner, MD, Co-Chairman

    J. Stephen Huff, MD

    Edward P. Sloan, MD, MPH

    William C. Dalsey, MD

    Members of the Clinical Policies Committee included:

    William C. Dalsey, MD (Chair 2000-2002, Co-Chair 2002-2003)

    Andy S. Jagoda, MD (Co-Chair 2002-2003, Chair 2003-2004)

    Wyatt W. Decker, MD

    Francis M. Fesmire, MD

    Steven A. Godwin, MD

    John M. Howell, MD

    Shkelzen Hoxhaj, MD (EMRA Representative 2002-2003)

    J. Stephen Huff, MD

    Alan H. Itzkowitz, MD (EMRA Representative 2000-2001)

    Edwin K. Kuffner, MD

    Thomas W. Lukens, MD, PhD

    Benjamin E. Marett, RN, MSN, CEN, CNA, COHN-S (ENA Representative 2002-2003)

    Thomas P. Martin, MD

    Jessie Moore, RN, MSN, CEN (ENA Representative 2001-2002)

    Barbara A. Murphy, MD

    Devorah Nazarian, MD

    Scott M. Silvers, MD

    Bonnie Simmons, DO

    Edward P. Sloan, MD, MPH

    Robert L. Wears, MD, MS

    Stephen J. Wolf, MD (EMRA Representative 2001-2002)

    Robert E. Suter, DO, MHA (Board Liaison 2000-2001)

    Susan M. Nedza, MD, MBA (Board Liaison 2001-2003)

    Rhonda Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

    At the time of publication, Dr. Jagoda, Dr. Huff, and Dr. Sloan were on the Advisory Board for Eisai Pharmaceuticals.

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