ED Seizure Management

Seizures are a common complaint seen in the Emergency Room. Some patients are straight forward with an obvious reason or history of seizures but for some, this may be their first seizure. So how do you differ in medical management with a patient that has new onset of seizures? The American College of Emergency Physicians (ACEP ) have created a clinical policy in 2014 to assist management of patients who present with seizures.

Key Points

  • No need to start antiepileptic drugs for resolved 1st unprovoked seizure without evidence of brain disease/injury
  • When restarting / loading antiepileptic drugs the route is not important unless status epilepticus
  • If status epilepticus refractory to benzodiazepines, add IV antiepileptic
  • Unprovoked seizures are considered a seizure without a precipitating factor in the last 7 days (nuerological/systemic/metabolic/toxic insult)

Start your treatment plan based on patient type:

Patient returned to baseline LOC with 1st generalized seizure that was UNPROVOKED

  • Admission is not required and do not initiate antiepileptic drugs
  • If returned to baseline with 1st generalized seizure but had prior precipitating factors that were greater than 7 days the admission is still NOT required. You may initiate antiepileptic drugs or refer to neurology

Patient returned to baseline LOC with 1st generalized seizure that was PROVOKED

  • Identify and manage the precipitating condition (hyponatremia, electrolyte abnormalities, withdrawal, toxins, encephalitis, lesions, etc)
  • You do not have to start antiepileptics, the goal is to treat the condition that cause the seizure

Patient returned to baseline LOC with known seizure disorder

  • Resume usual antiepileptics
  • Consider IV or PO load
  • Evidence lacks to support either PO or parental route
    • Carbamazepine 8mg/kg PO
    • Gabapentin 300mg PO TID x 3 days
    • Lacosamide PO or IV ( loading dose has not been studied)
    • Lamotrigine 6.5mg/kg PO (if tolerated, no rash in last 6 months and only off of drug for less than 5 days)
    • Levetiracetam 1500mg PO or rapid IV (up to 60mg/kg)
    • Phenytoin 20mg/kg in 3 diviided doses Q2H PO (max 400mg per dose)
    • Phenytoin 18mg/kg IV
    • Fosphenytoin 18 PE/kg IV
    • Valproate up to 30mg/kg IV

Patient NOT returning to baseline LOC (status epilepticus)

  • Seizure lasting 20 min or more or intermittent seizures without regaining full consciousness
  • First line treatment is to dose patient optimally with benzodiazepines
  • Next you should identify and manage the underlying cause
  • Second line treatment is to add antiepileptics if refractory to benzodiazepines
    • Phenytoin 18-20mg/kg IV
    • Fosphenytoin 18-20 PE/kg IV
    • Valproate 20-30mg/kg IV at 40mg/min
    • Levetiracetam 30mg-50mg/kg IV at 100mg/min
    • Propofol 2mg/kg IV, may repeat dose in 3-5min; maintenance 5mg/kg/h
    • Phenobarbital 10-20mg/kg IV, may repeat 5-10mg/kg at 10min

* Although neuroimaging is not discussed, immediate non contrast CT of the head is possibly useful when there is an abnormal physical exam, predisposing history, or focal onset of seizures. If the patient has new onset of seizures a baseline CT of the head should be completed. If a structural lesion is found on imaging this can be helpful with decision making.

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