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Seizure (Adult)

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures (May 2004)

Complete Clinical Policy on Seizure  (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments (EDs).

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with seizures.

Exclusion Criteria. This guideline is not intended for pediatric patients.

Critical Questions

1. 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?

  • Level A recommendations. None specified.


  • Level B recommendations. (1) Determine a serum glucose and sodium level on patients with a first-time seizure with no comorbidities who have returned to their baseline.
    (2) Obtain a pregnancy test if a woman is of child-bearing age.
    (3) Perform a lumbar puncture, after a head computed tomography (CT) scan, either in the ED or after admission, on patients who are immunocompromised.


  • Level C recommendations. None specified.

2. Which new-onset seizure patients who have returned to a normal baseline require a head CT scan in the ED?

  • Level A recommendations: None specified.


  • Level B recommendations: (1) When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure.
    (2) Deferred outpatient neuroimaging may be used when reliable follow-up is available.


  • Level C recommendations. None specified.

3. 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?

  • Level A recommendations: None specified.


  • Level B recommendations: None specified.


  • Level C recommendations: (1) Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up.
    (2) 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.

4. 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?

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. Administer an intravenous or oral loading dose of phenytoin or intravenous or intramuscular fosphenytoin, and restart daily oral maintenance dosing.

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

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. Administer 1 of the following agents intravenously: “high-dose phenytoin,” phenobarbital, valproic acid, midazolam infusion, pentobarbital infusion, or propofol infusion.

6. When should EEG testing be performed in the ED?

  • Level A recommendations. None specified.


  • Level B recommendations. None specified.


  • Level C recommendations. 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.

Purpose of ACEP's Clinical Policies

Clinical Findings and Strength of Recommendations