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Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are provided at the end of the "Major Recommendations" field.
- 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 (ED) to prevent additional seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
- Emergency physicians may initiate antiepileptic medication* in the ED, 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 ED, should the patient be admitted to the hospital to prevent adverse events?
Patient Management 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 ED.
- In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer intravenous (IV) or oral medication at their discretion.
- In ED 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?
Patient Management Recommendations
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer IV phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer IV levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Definitions:
Strength of Evidence
Literature Classification Schema*
Design/Class Therapy† Diagnosis‡ Prognosis§ 1 Randomized, controlled trial or meta-analysis of randomized trials Prospective cohort using a criterion standard or meta-analysis of prospective studies Population prospective cohort or meta-analysis of prospective studies 2 Nonrandomized trial Retrospective observational Retrospective cohort
Case control3 Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
†Objective is to measure therapeutic efficacy comparing interventions.
‡Objective is to determine the sensitivity and specificity of diagnostic tests.
§Objective is to predict outcome including mortality and morbidity.
Approach to Downgrading Strength of Evidence*
Design/Class Downgrading 1 2 3 None I II III 1 level II III X 2 levels III X X Fatally flawed X X X *See the "Description of Methods Used to Analyze the Evidence" field for more information.
Strength of recommendations regarding each critical question were made by subcommittee members using results from strength of evidence grading, expert opinion, and consensus among subcommittee members according to the following guidelines:
Strength of Recommendations
Level A recommendations. Generally accepted principles for patient care that reflect a high degree of clinical certainty (i.e., 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 (i.e., 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 any adequate published literature, based on expert consensus. In instances where 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 consequences, and publication bias, among others, might lead to such a downgrading of recommendations.
Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are provided at the end of the "Major Recommendations" field.
- 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 (ED) to prevent additional seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
- Emergency physicians may initiate antiepileptic medication* in the ED, 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 ED, should the patient be admitted to the hospital to prevent adverse events?
Patient Management 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 ED.
- In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer intravenous (IV) or oral medication at their discretion.
- In ED 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?
Patient Management Recommendations
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer IV phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer IV levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Definitions:
Strength of Evidence
Literature Classification Schema*
Design/Class Therapy† Diagnosis‡ Prognosis§ 1 Randomized, controlled trial or meta-analysis of randomized trials Prospective cohort using a criterion standard or meta-analysis of prospective studies Population prospective cohort or meta-analysis of prospective studies 2 Nonrandomized trial Retrospective observational Retrospective cohort
Case control3 Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
†Objective is to measure therapeutic efficacy comparing interventions.
‡Objective is to determine the sensitivity and specificity of diagnostic tests.
§Objective is to predict outcome including mortality and morbidity.
Approach to Downgrading Strength of Evidence*
Design/Class Downgrading 1 2 3 None I II III 1 level II III X 2 levels III X X Fatally flawed X X X *See the "Description of Methods Used to Analyze the Evidence" field for more information.
Strength of recommendations regarding each critical question were made by subcommittee members using results from strength of evidence grading, expert opinion, and consensus among subcommittee members according to the following guidelines:
Strength of Recommendations
Level A recommendations. Generally accepted principles for patient care that reflect a high degree of clinical certainty (i.e., 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 (i.e., 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 any adequate published literature, based on expert consensus. In instances where 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 consequences, and publication bias, among others, might lead to such a downgrading of recommendations.
Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are provided at the end of the "Major Recommendations" field.
- 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 (ED) to prevent additional seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
- Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
- Emergency physicians may initiate antiepileptic medication* in the ED, 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 ED, should the patient be admitted to the hospital to prevent adverse events?
Patient Management 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 ED.
- In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Patient Management Recommendations
Level A recommendations. None specified.
Level B recommendations. None specified.
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer intravenous (IV) or oral medication at their discretion.
- In ED 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?
Patient Management Recommendations
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer IV phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer IV levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Definitions:
Strength of Evidence
Literature Classification Schema*
Design/Class Therapy† Diagnosis‡ Prognosis§ 1 Randomized, controlled trial or meta-analysis of randomized trials Prospective cohort using a criterion standard or meta-analysis of prospective studies Population prospective cohort or meta-analysis of prospective studies 2 Nonrandomized trial Retrospective observational Retrospective cohort
Case control3 Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)Case series
Case report
Other (e.g., consensus, review)*Some designs (e.g., surveys) will not fit this schema and should be assessed individually.
†Objective is to measure therapeutic efficacy comparing interventions.
‡Objective is to determine the sensitivity and specificity of diagnostic tests.
§Objective is to predict outcome including mortality and morbidity.
Approach to Downgrading Strength of Evidence*
Design/Class Downgrading 1 2 3 None I II III 1 level II III X 2 levels III X X Fatally flawed X X X *See the "Description of Methods Used to Analyze the Evidence" field for more information.
Strength of recommendations regarding each critical question were made by subcommittee members using results from strength of evidence grading, expert opinion, and consensus among subcommittee members according to the following guidelines:
Strength of Recommendations
Level A recommendations. Generally accepted principles for patient care that reflect a high degree of clinical certainty (i.e., 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 (i.e., 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 any adequate published literature, based on expert consensus. In instances where 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 consequences, and publication bias, among others, might lead to such a downgrading of recommendations.
This clinical policy from the American College of Emergency Physicians is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department. A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer four critical questions. A literature search was performed, the evidence was graded, and recommendations were given based on the strength of the available data in the medical literature.
Guidelines are copyright © 2014 American College of Emergency Physicians. All rights reserved. The summary is provided by the Agency for Healthcare Research and Quality.