• ABCD
  • Airway – suction, lateral decubitus positioning.
  • Breathing – supplemental oxygen as patient may become apneic.
  • Circulation.
  • Dextrose – Bedside glucose reading.
• Monitors – get to monitored bed/monitors attached.
• Oxygen – Supplemental O2.
• Vital signs.
• IV access.
• Consider ECG g.
• Treatment of status epilepticus (see “Recommended Treatment” below”).

• Seizures are sudden changes in neurologic function caused by inappropriate discharge of electrical activity in the brain.
• Epilepsy is a clinical syndrome where an individual experiences two or more provoked seizures more than 24 hours apart.
• Status epilepticus is characterized by seizures lasting more than 5 minutes or recurrent seizures, without return to baseline mental status.
• Lifetime seizure risk is 2-5%, and seizures account for 1-2% of ED visits.⁽¹⁾

Primary goals of the ED physician managing seizure in the adult:

• Look for and treat reversible causes.
• Identify and rapidly manage status epilepticus.

Known Seizure history

• Blood glucose, pertinent anticonvulsant drug levels.⁽²⁾
• History is important to determine cause:
  • Often caused by lack missed medication doses.⁽²⁾
    • Obtain serum drug level and consider loading dose.
    • If serum drug level not available (e.g. Leviteracetam, lacosamide) – give usual dose.
  • Consider ruling-out secondary causes (see workup for new seizure).
  • Look for change in previous seizure pattern (in this case approach as new seizure).

New Seizure

• Rule-out seizure mimics (syncope, CVA, migraine, psychogenic nonepileptic seizures).
• Determine if provoked vs unprovoked (See Table 1).

Imaging⁽²⁾

• CT Head (NCCT) for all adult patients with:

1. 1. First ever seizure.
   2. Change in established seizure pattern.
   3. Concern for acute intracranial process (persisting focal deficits, head trauma, anticoagulant use, history of cancer).

Other Investigations:

• EEG: not routinely available. Consider for persistent/refractory status epilepticus, evaluation of non-convulsant status epilepticus.
• Site-specific injury for suspect injuries (i.e., spinal trauma, shoulder dislocations, etc.).

Table 1 – Etiology and Investigations for Provoked Seizure

Status Epilepticus (SE)

Step 1: Abortive therapy

• Preferred agents based on access.⁽³⁾
  • Lorazepam (IV)
  • Midazolam (IM)
  • Diazepam (IV / rectal)
• Lorazepam may carry lower risk than diazepam for continuation of status epilepticus requiring different drug or general anesthesia.⁽⁴⁾
• Lorazepam is better than phenytoin for cessation of seizures.⁽⁴⁾

Step 2: Anti-epileptic drug (AED)

All patients in SE require AED in addition to benzodiazepine abortive therapy, whether or not the seizure has aborted.⁽³⁾ Required to prevent recurrence, or for failure of emergent initial therapy.

• Adult, no seizure history
  • Phenytoin/fosphenytoin.⁽³⁾
• Adult, epilepsy
  • Valproate sodium.⁽³⁾
  • IV bolus of patient’s maintenance medication, if available may be used first.
• Other agents: phenobarbital, levetiracetam, continuous infusion midazolam.

If seizure cessation after step 2, stop.

If seizure activity persists, patient has refractory SE. Continue to step 3.

Step 3: Refractory Status Epilepticus (20-60 min after initiation of second agent)(3)

• Option 1: Repeat bolus of AED chosen in step 2.
  • If trial of option 1 fails, proceed to option 2.
• Option 2: Continuous infusion AED
  • Medication options: Midazolam, propofol, phenobarbital.
  • Note: Continuous infusion AEDs generally requires ventilatory assistance and cardiovascular monitoring. Vasopressor agents may be required for hemodynamic support.
  • If trial of option 2 fails, trial with a second continuous infusion agent.
• Patients in this category should be admitted to ICU/neuro ICU, or transferred to a facility with this service.

Aborted Seizure (Non-status epilepticus)

Patient with documented seizure history/disorder:

• Home anti-epileptic drugs (AED) – May require adjustment in maintenance dose.
  • Requires follow-up with Neurologist/PCP.

First-time seizure:

• Not all with first-time seizures require preventative AED. Those with high-risk features may receive treatment⁽⁵⁾, though some experts believe that prophylactic AEDs should not be routinely started in the ED.⁽⁶⁾
• High-risk features include⁽⁵⁾:
  • Epileptiform activity on EEG.
  • Abnormal brain imaging.
  • Nocturnal seizure.
  • Severe head trauma.
  • Epilepsy syndrome (the signs and symptoms classic for an epileptic condition).
  • 2 unprovoked seizures >24 hours apart.
• If high-risk criteria are met, and AEDs are started in the ED, initiating treatment with monotherapy agent is advised, as per Table 1 in AAFP article (medication will vary by seizure type). https://www.aafp.org/pubs/afp/issues/2017/0715/p87.html
• Consultation with a specialist is recommended for first-time unexplained seizure and those with high risk seizures.

• Pregnant > 20 weeks.
• New focal abnormality.
• Mental status not returning to baseline.
• Refractory SE.

• If a patient requires admission and neurology is not available in house, transfer once stabilized in consultation with neurology.
• Refractory SE, patient should be monitored in ICU/neuro ICU, which may require transfer once stabilized.

• Consult neurology (or arrange for rapid follow-up) if:
  • New seizure of undetermined etiology.
  • History of seizure with new change in seizure pattern.
• Consult ICU/neuro-ICU if:
  • Refractory SE.

• Must make full neurological recovery.
• All patients with first episode of generalized seizure should be counselled to stop driving and this conversation should be documented.⁽⁶⁾

1. Patient information:

   • After a first, unprovoked seizure⁽⁵⁾:
     • Risk of recurrence: 50% over 5 years. 1/3 of this risk is within first year.
     • Adult > 65: Risk of recurrence: 80% lifetime, 53% within first year.
     • Initiating AED therapy decreases risk of recurrence by 35% over next 2 years.
   • Certain activities are high-risk and should be avoided prior to consultation with neurologist. These should be discussed prior to discharge and include:
     • Driving
       • https://www2.gov.bc.ca/gov/content/transportation/driving-and-cycling/roadsafetybc/medical-fitness/medical-prof/med-standards/17-seizures#17.6.1
         • Return to driving laws vary by seizure type, and class of driver (commercial vs non-commercial).
       • Operating heavy machinery.
       • Swimming.
       • Anything activity where a seizure would put themselves or others at-risk.

   A number of handouts are available from the BC Epilepsy Society including a variety of information sheets, seizure first aid and safety and wellness guides: https://bcepilepsy.com/information-sheets-brochures/

   
   

1. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures. Ann Emerg Med. 2004;43(5):605–25.

   
   

2. Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D., Cline DM. Tintinalli’s Emergency Medicine 8th Ed. 8th ed. McGraw-Hill; 2016.

   
   

3. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3–23.

   
   

4. Prasad M, Krishnan PR, Sequeira R, Al-Roomi K. Anticonvulsant therapy for status epilepticus. Cochrane database Syst Rev. 2014 Sep 10;2014(9).

   
   

5. Liu G, Slater N, Perkins A. Epilepsy: Treatment Options. Am Fam Physician. 2017 Jul 15;96(2):87–96.

   
   

6. Breen DP, Dunn MJG, Davenport RJ, Gray AJ. Epidemiology, clinical characteristics, and management of adults referred to a teaching hospital first seizure clinic. Postgrad Med J. 2005 Nov;81(961):715–8.

   
   

7. Smith EF, Cantrill S V., Campbell M, Colucciello SA, Dalsey WC, Fesmire FM, et al. Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. American College of Emergency Physicians. Ann Emerg Med. 1997;29(5):706–24.

   
   

8. Kwon CS, Wong B, Agarwal P, Lin JY, Mazumdar M, Dhamoon M, et al. Nonelective hospital admissions, discharge disposition, and health services utilization in epilepsy patients: A population-based study. Epilepsia. 2020 Sep 1;61(9):1969–78.