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Seizure (Jan 2014)

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

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

  • 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?

    Recommendations
    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.
    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.
  • 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?

    Recommendations
    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.

    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.

  • 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?

    Recommendations
    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.
    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.

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Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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