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Seizure (Adult)

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures (January 2014)

Complete Clinical Policy on Seizures

Scope of Application. This guideline is intended for physicians working in emergency departments.

Inclusion Criteria. This guideline is intended for adult patients aged 18 years and older presenting to the emergency department with generalized convulsive seizures.

Exclusion Criteria. This guideline is not intended for pediatric patients, patients with complex partial seizures, patients with acute head trauma or multisystem trauma, patients with brain mass or brain tumor, immunocompromised patients, or patients with eclampsia.


Critical Questions

1. In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the emergency department to prevent additional seizures?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. 
(1) Emergency physicians need not initiate antiepileptic medication* in the emergency department for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
(2) Emergency physicians need not initiate antiepileptic medication* in the emergency department for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
(3) Emergency physicians may initiate antiepileptic medication* in the emergency department, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.
*Antiepileptic medication in this document refers to medications prescribed for seizure prevention.


2. In patients with a first unprovoked seizure who have returned to their baseline clinical status in the emergency department, should the patient be admitted to the hospital to prevent adverse events?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the emergency department.


3. In patients with a known seizure disorder in which resuming their antiepileptic medication in the emergency department is deemed appropriate, does the route of administration impact recurrence of seizures?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. When resuming antiepileptic medication in the emergency department is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.


4. In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?

Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in emergency department patients with refractory status epilepticus who have failed treatment with benzodiazepines.

Level B recommendations. Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in emergency department patients with refractory status epilepticus who have failed treatment with benzodiazepines.

Level C recommendations. Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in emergency department patients with refractory status epilepticus who have failed treatment with benzodiazepines.


Purpose of ACEP’s Clinical Policies
Clinical Findings and Strength of Recommendations