In this issue of EM Practice Guidelines Update, 3 practice guidelines that address the management of seizures are reviewed. The recommendations within the 3 documents focus on decisionmaking around the patient with seizures refractory to first-line therapy, the management of patients with an unprovoked first seizure, and options for anticonvulsant drug delivery.

 

Status epilepticus complicates up to 7% of seizures in the emergency department (ED), with a significant mortality rate.¹ Patients with ongoing seizures demand immediate general resuscitative and specific therapeutic maneuvers; good evidence exists to direct clinicians in managing these dangerous presentations. Stable seizure patients commonly seek emergency care for firsttime seizures, breakthrough seizures, or unrelated complaints that affect their ongoing anticonvulsant therapy. High-quality trials examining issues that arise in the care of these patients are few; however, consensus-based recommendations offer guidance to clinicians navigating controversial testing and treatment scenarios.

 

Practice Guideline Impact

• Intravenous (IV) lorazepam is first-line therapy for active seizures. Patients who continue to seize after 2 benzodiazepine doses should be treated with propofol or barbiturates.
• Diagnostic lumbar puncture is indicated in immunocompromised patients with an unprovoked first seizure.
• EEG monitoring is indicated to rule out nonconvulsive status epilepticus in patients receiving aggressive therapy for generalized convulsive status epilepticus.