From the Guidelines
The most critical step in managing a patient with multiple seizures in the Emergency Department is to follow a stepwise protocol that prioritizes stabilization of airway, breathing, and circulation, and then proceeds with first-line treatment using intravenous benzodiazepines, such as lorazepam or diazepam, as recommended by the American College of Emergency Physicians (ACEP) in their 2024 clinical policy 1. When taking a history for an ED patient presenting with multiple seizures, it is essential to ask questions that help identify the underlying cause of the seizures, as well as any potential contributing factors.
Key Questions to Ask
- What was the duration and frequency of the seizures?
- Were there any precipitating factors, such as fever, head trauma, or substance use?
- Has the patient had any previous seizures or a history of epilepsy?
- Is the patient currently taking any antiseizure medications, and if so, are they compliant with their regimen?
- Has the patient recently started or stopped any medications that could potentially lower the seizure threshold, such as tramadol or cocaine?
Importance of Diagnostic Workup
A thorough diagnostic workup, including blood glucose, electrolytes, toxicology screening, and neuroimaging, should be performed to identify underlying causes of the seizures, as recommended by the ACEP clinical policy 1.
Continuous EEG Monitoring
Continuous EEG monitoring is valuable for patients with persistent altered mental status, as it can help identify subclinical nonconvulsive status epilepticus, which can be a complication of multiple seizures 1.
Treatment Protocol
The treatment protocol should include first-line therapy with intravenous benzodiazepines, followed by second-line therapy with agents such as fosphenytoin, valproic acid, or levetiracetam, if seizures persist, as outlined in the ACEP clinical policy 1.
Refractory Status Epilepticus
For refractory status epilepticus, intubation and continuous infusion of propofol, midazolam, or ketamine may be necessary, as recommended by the ACEP clinical policy 1.
From the Research
Patient History for ED Patient Presenting with Multiple Seizures
When taking a history for an ED patient presenting with multiple seizures, the following questions should be asked:
- What is the patient's medical history, including any previous seizures or epilepsy diagnosis? 2
- What is the patient's current medication list, including any antiepileptic drugs? 3, 4, 5
- What were the circumstances surrounding the seizures, including any potential triggers or precipitating factors? 6
- How long did the seizures last, and were they generalized or focal? 4, 2
- Has the patient experienced any other symptoms, such as headache, confusion, or weakness? 2
- Has the patient had any recent head trauma or injuries? 3, 5
- Are there any family members with a history of seizures or epilepsy? 2
Seizure Prophylaxis and Management
For patients with multiple seizures, the following should be considered:
- Seizure prophylaxis may be indicated, particularly in patients with traumatic brain injury 3, 5
- Antiepileptic drugs such as phenytoin, levetiracetam, and valproate may be used for seizure prophylaxis 3, 4, 5
- The choice of antiepileptic drug should be individualized based on the patient's medical history, current medications, and potential side effects 4, 5
- Status epilepticus should be promptly recognized and treated with intravenous medications such as lorazepam, phenytoin, or levetiracetam 4, 2
Diagnostic Considerations
The following diagnostic considerations should be kept in mind:
- A thorough physical examination and medical history should be performed to identify potential causes of the seizures 2, 6
- Laboratory tests, such as electrolyte panels and toxicology screens, may be ordered to rule out underlying causes of the seizures 2
- Imaging studies, such as CT or MRI scans, may be ordered to evaluate for structural abnormalities or traumatic brain injury 3, 2
- Electroencephalography (EEG) may be ordered to evaluate for seizure activity or to monitor the patient's response to treatment 4, 6