Annals of Emergency Medicine. 2004;43:605-625. Link to this: http://www.acep.org/WorkArea/DownloadAsset.aspx?id=8820
This document was developed by a committee and subcommittee organized and funded by the American College of Emergency Physicians (ACEP). Panel members are listed; their affiliations/ qualifications are not. The group identified 6 critical questions and utilized an explicit strategy for their literature search and review. Evidence was evaluated for quality according to predefined criteria and sorted into 4 classes (I, II, III, or X-fatally flawed). Recommendations were graded based on the strength of evidence for each question. A: high degree of certainty; B: moderate degree of certainty; C: based on preliminary, inconclusive, or conflicting evidence or panel consensus. Disclosures were reported for the subcommittee for this policy. The policy targets clinicians working in hospital-based EDs. The guidelines presented in the policy apply to adult patients presenting to the ED with seizures. Pediatric patients are excluded.
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?
Recommendation 1 (Level B): Determine a serum glucose and sodium level on patients with a first-time seizure with no comorbidities who have returned to their baseline.
Recommendation 2 (Level B): Obtain a pregnancy test if a woman is of childbearing age.
Recommendation 3 (Level B): Perform a lumbar puncture, after a head computed tomography (CT) scan, either in the ED or after admission, on patients who are immunocompromised.
Which new-onset seizure patients who have returned to a normal baseline require a head CT scan in the ED?
Recommendation 4 (Level B): When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure.
Recommendation 5 (Level B): Deferred outpatient neuroimaging may be used when reliable follow-up is available.
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?
Recommendation 6 (Level C): Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up.
Recommendation 7 (Level C): Patients with a normal neurologic examination, no comorbidities, and no known structural brain disease do not need to be started on an antiepileptic drug in the ED.
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?
Recommendation 8 (Level C): Administer an intravenous or oral loading dose of phenytoin or intravenous or intramuscular fosphenytoin, and restart daily oral maintenance dosing.
What agent(s) should be administered to a patient in status epilepticus who continues to seize after having received benzodiazepine and phenytoin?
Recommendation 9 (Level C): Administer 1 of the following agents intravenously: “high-dose phenytoin,” phenobarbital, valproic acid, midazolam infusion, pentobarbital infusion, or propofol infusion.
When should EEG testing be performed in the ED?
Recommendation 10 (Level C): Consider an emergent EEG in patients suspected of being in nonconvulsive status epilepticus or in subtle convulsive status epilepticus, patients who have received a long-acting paralytic, or patients who are in a drug-induced coma.
© 2004 American College of Emergency Physicians® (ACEP). Reprinted with permission from ACEP. All rights reserved.