j. stephen huff, md 1 what the acep seizure clinical policy doesn’t tell us about adult seizure...

J. Stephen Huff, MD1

What the ACEP Seizure What the ACEP Seizure Clinical Policy Clinical Policy Doesn’t Tell UsDoesn’t Tell Us

about Adult Seizure and about Adult Seizure and Status Epilepticus Patients…Status Epilepticus Patients…

A view from the real clinical world….


J. Stephen Huff, MD

Associate ProfessorEmergency Medicine and NeurologyDepartment of Emergency MedicineUniversity of Virginia Health System

Charlottesville, Virginia, United States


ObjectivesObjectives

• Review Clinical Policy on Seizures…

• Discuss policy development

• Show limitations of policy development

• Demonstrate practical use of policy


ProcessProcess

• Present brief case

• Review ACEP Clinical Policy

• Show policy application and limitations


Ann Emerg Med 2004;43:605Ann Emerg Med 2004;43:605

Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures

Not a comprehensive manual

No substitute for clinician’s judgment


A word about policy development…A word about policy development…

• Key questions from membership

• Subcommittee formation

• Literature search

• Review and grade literature

• Strength of evidence recommendations

• Peer and expert review


Level of RecommendationsLevel of Recommendations• Level A recommendations

– High degree of clinical certainty– Strength of evidence Class I or multiple II

• Level B recommendations– Reflect moderate clinical certainty– Class II studies or other

• Level C recommendations– Preliminary or inconclusive evidence– Panel consensus


Clinical History 1Clinical History 1A 21 year-old college student presents to the ED after a witnessed generalized first seizure at a party. His examination is normal at this time. Past medical history is unremarkable. His history and that of his roommates indicate that there was nothing unusual about the evening. Are additional tests necessary?


New-Onset Seizure: LabNew-Onset Seizure: Lab• What laboratory tests are indicated in the

otherwise healthy adult patient with a new-onset seizure who has returned to baseline normal neurologic status?


• Level A recommendations - None

New-Onset Seizure: LabNew-Onset Seizure: Lab


New-Onset Seizure: LabNew-Onset Seizure: Lab• Level B recommendations

• 1. Determine a serum glucose and sodium level on patients with 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.


New-Onset Seizure: LabNew-Onset Seizure: Lab• The policy suggests that a serum glucose

and sodium determinations are appropriate in this patient. Would you do anything differently with regard to laboratory testing?


Case 1 - ConclusionCase 1 - Conclusion• The patient and friends had been

experimenting with cocaine• Toxicologic analysis confirmed the presence

of cocaine metabolites• The cocaine is the likely precipitant of his

seizure. This patient should not be given a diagnosis of idiopathic epilepsy nor does he need anti-epileptic medications administered.


New-Onset Seizure: LabNew-Onset Seizure: Lab• Commentary- Evidence-based

recommendations suggest that laboratory work is of limited utility

• In practice routine testing is prevalent

• An approach directed by history and physical will have higher yield than an undirected approach


Clinical History 2Clinical History 2A 30 year-old graduate student comes to the ED with a friend following a generalized convulsion. He is healthy and takes no medications. He had been evaluated and released from the ED after a bicycle accident one week before and had attended classes this week in spite of an unusual headache. His examination is normal at this time. Past medical history is unremarkable. Should imaging be done in the ED?


New-Onset Seizure: CTNew-Onset Seizure: CT

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


New-Onset Seizure: CTNew-Onset Seizure: CT



New-Onset Seizure: CTNew-Onset Seizure: CT• Level B recommendations

1. When feasible, perform 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.


New-Onset Seizure: CTNew-Onset Seizure: CT• The policy suggests that imaging may be

deferred in this patient. Would you do anything different?

PicturePicture


Case 2Case 2• Imaging showed a large frontal epidural

hematoma without midline shift. This illustrates the insensitivity at times of the bedside neurologic examination. The history of recent trauma should trigger the decision to pursue neuroimaging.


New-Onset Seizure: CTNew-Onset Seizure: CT• Commentary-the history of trauma was

the driving force in this case• In US practice, if logistically possible,

patients will likely be imaged in the ED• The policy attempts to allow the clinician

options if there is difficulty in getting prompt CT, or if elective MRI imaging might be promptly obtained

• As technology evolves policy will change


Clinical History 3Clinical History 3A visiting clerical worker has a seizure while doing an audit at a local business. He is awake, alert, and examination is normal. There is no seizure history or significant medical history. He blames the event on late hours and poor sleeping quarters. Laboratory evaluation and initial imaging are performed and are unremarkable.

What would you do?


New-Onset Seizure: AdmissionNew-Onset Seizure: Admission• 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 B recommendations - None

New-Onset Seizure: AdmissionNew-Onset Seizure: Admission


• Level C recommendations1. 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.




• The policy suggests that this patient may be discharged for outpatient follow-up without starting on medications…

• Do you agree?


• Level C recommendations1. 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.



Case 3Case 3• The early seizure recurrence risk is

simply not known. If discharged, the patient must have a stable social situation. Staying alone in a hotel room is not sufficient.

• Perhaps the best option is to admit the patient for observation and an expedited diagnostic work-up


New-Onset Seizure: AdmissionNew-Onset Seizure: Admission• Commentary-Policy attempts to

recognize the varied approach to this patient type

• “new-onset seizures do not need to be admitted”- with reservations– normal exam– structurally normal brain– safety


Case 4Case 4• A patient with a known seizure disorder for

many years and a history of good seizure control presents to the ED after a seizure. He admits that he has missed his only medication, phenytoin, for several days. A phenytoin level is very low.


Effective Dosing: PhenytoinEffective Dosing: Phenytoin• 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

Effective Dosing: PhenytoinEffective Dosing: Phenytoin


Effective Dosing: PhenytoinEffective Dosing: Phenytoin• Level C recommendations

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


Case 4Case 4

• What would you do?– IV phenytoin or fosphenytoin?

– PO phenytoin loading strategy? How?

– Resume medications?


Case 4Case 4• The patient is given an oral loading of

phenytoin at 18 mg/kg and started back on his seizure medication. He has some nausea following the medication


Effective Dosing: PhenytoinEffective Dosing: Phenytoin

• Commentary- No data exist to rationally guide therapy

• The risk of early seizure recurrence in this patient population is not known


Case 5Case 5• A patient with a history of difficult-to-

control seizures presents to the emergency department minimally responsive after a flurry of seizures. There have been at least three witnessed seizures while in route. Current medications include valporate and levetiracetam.


Case 5Case 5• Airway control is thought to be adequate

when supplemented with a nasopharyngeal airway

• Lorazepam 4 mg is administered intravenously

• Phenytoin loading is accomplished


Status Epilepticus: Refractory Status Epilepticus: Refractory • What agent(s) should be administered to

a patient in status epilepticus who continues to seize after having received a benzodiazepine and a phenytoin?


Status Epilepticus: RefractoryStatus Epilepticus: Refractory• Level A recommendations

– None specified



Status Epilepticus: RefractoryStatus Epilepticus: Refractory• Level C recommendations• Administer 1 of the following agents

intravenously – “high-dose phenytoin”

– phenobarbital

– valproic acid

– midazolam infusion

– pentobarbital infusion

– propofol infusion.


Case 5Case 5• The clinical policy intimates that many

options are equally effective (or ineffective).

• What would you do in this case?

• What would you do?– Which drug?

– How much?


Case 5Case 5• Many opinions

• No data exist to guide specific therapies

• Reasonable to empirically administer valproate in this patient, particularly if levels are demonstrated to be low


Status Epilepticus: RefractoryStatus Epilepticus: Refractory

• Commentary- Many options possible without clear superiority of one regimen

• Midazolam infusion

• Propofol infusion


Case 6Case 6• A patient with a known seizure disorder

and static encephalopathy (cerebral palsy) has a seizure

• Normally walks with assistive devices but is high-functioning intellectually

• Lives with family and takes two medications for seizures, valproate and carbamazepine


Case 6Case 6• He receives lorazepam 4 mg IV in route

to the hospital

• No further generalized convulsive activity is observed

• Occasional twitching of the eyelids with jerking of the eyes to the left

• Not awakening after 30 minutes


EEG in EDEEG in ED• When should EEG testing be

performed in the ED?


EEG in EDEEG in ED• Level A recommendations

– None specified



EEG in EDEEG in ED• 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 drug-induced coma.


Case 6Case 6• The clinical policy intimates that an

emergency EEG should be considered

• What would you do in this case?


Case 6Case 6• Though access to EEG varies widely, it

is prudent to consult a neurologist or transfer such a patient for consideration of EEG

• Status epilepticus was present on EEG

• Additional medication was added…


Case 6Case 6• The natural history of “subtle” status

epilepticus, or non-convulsive status epilepticus is still being delineated, but there is consensus that the excessive electrical activity alone is injurious to the brain


EEG in EDEEG in ED

• Commentary-Access to EEG varies widely but it is prudent to consult a neurologist or transfer such a patient for consideration of EEG

• This is an evolving clinical area without strong published evidence to guide recommendations.


Key Learning PointsKey Learning Points• Reviewed ACEP Clinical Policy

• Showed interactions with clinical world….


Questions??Questions??

[email protected]

J. Stephen Huff, [email protected]

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j. stephen huff, md 1 what the acep seizure clinical policy doesn’t tell us about adult seizure...

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