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Seizure

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, patients with eclampsia or patients in the out-of-hospital environment.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

 

Critical Questions

  • In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of benzodiazepine, which agent or agents should be administered next to terminate seizures?

    Recommendations
    Level A Recommendations

    Emergency physicians should treat seizures refractory to appropriately dosed benzodiazepines with a second-line agent. Fosphenytoin, levetiracetam, or valproate may be used with similar efficacy.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

    Level A Recommendations

    Emergency physicians should treat seizures refractory to appropriately dosed benzodiazepines with a second-line agent. Fosphenytoin, levetiracetam, or valproate may be used with similar efficacy.

    Level B Recommendations

    None specified.

    Level C Recommendations

    None specified.

Download the Policy

PDF Icon Seizures.pdf June 2024

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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