What is the recommended approach for managing a patient with multiple seizures in the Emergency Department (ED)?

From the Guidelines

When managing a patient with multiple seizures in the Emergency Department, it is crucial to follow a stepwise protocol that prioritizes stabilization of airway, breathing, and circulation, and then proceeds with first-line treatment using intravenous benzodiazepines, followed by second-line therapy if necessary, as recommended by the American College of Emergency Physicians (ACEP) clinical policy 1.

Key Considerations

• The patient's history should include questions about the onset and duration of seizures, any potential triggers, and current medications, including antiseizure drugs and any substances that may lower the seizure threshold, such as tramadol or cocaine 1.
• First-line treatment should be initiated with intravenous benzodiazepines, such as lorazepam, diazepam, or midazolam, with dosing adjusted according to the patient's response and weight.
• If seizures persist, second-line therapy with fosphenytoin, valproic acid, or levetiracetam should be considered, with dosing and administration rates guided by the patient's clinical status and the potential for adverse effects.
• For patients in status epilepticus, defined as seizures lasting longer than 5 minutes or multiple seizures without a return to neurologic baseline, aggressive management including intubation and continuous EEG monitoring may be necessary, with treatment options including propofol, midazolam, or pentobarbital 1.

Underlying Causes

• Identifying and addressing underlying causes of seizures, such as metabolic abnormalities, infection, trauma, or toxins, is essential to prevent further seizure activity and improve patient outcomes.
• Laboratory testing, neuroimaging, and toxicology screens should be used as needed to guide diagnosis and treatment.
• The patient's medication regimen, including antiseizure drugs, should be carefully evaluated and adjusted as necessary to ensure optimal seizure control and minimize adverse effects.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected.

When taking a history for an ED patient presenting with multiple seizures, key questions to ask include:

• History of present illness: What was the onset and duration of the seizures?
• Past medical history: Has the patient had seizures before? Are they taking any medications for seizure control?
• Medication history: Is the patient taking any medications that could lower the seizure threshold?
• Substance use history: Does the patient use any substances that could contribute to seizures, such as alcohol or illicit drugs?
• Trauma history: Has the patient experienced any recent head trauma? The patient should be evaluated for correctable causes of status epilepticus, such as hypoglycemia or hyponatremia, and treated accordingly 2.

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?
• What is the patient's current medication list, including any antiepileptic drugs?
• What were the circumstances surrounding the seizures, including any potential triggers or precipitating factors?
• How long did the seizures last and what were the characteristics of the seizures (e.g. generalized, focal, etc.)?
• Has the patient experienced any recent head trauma or other injuries that could be contributing to the seizures?
• Are there any other symptoms or concerns that the patient is experiencing, such as fever, headache, or confusion?

Seizure Prophylaxis in Traumatic Brain Injury

For patients with traumatic brain injury, seizure prophylaxis may be indicated to prevent post-traumatic seizures. The following points should be considered:

• Phenytoin has been extensively studied for seizure prophylaxis in traumatic brain injury and is recommended by the Brain Trauma Foundation and the American Academy of Neurology 3
• Levetiracetam has demonstrated comparable efficacy to phenytoin for seizure prophylaxis and may be a reasonable alternative 3, 4
• The use of antiepileptics for seizure prophylaxis should be limited to the first seven days after traumatic brain injury, as recommended by the Brain Trauma Foundation and the American Academy of Neurology 3

Management of Patients with Seizures in the ED

The following points should be considered when managing patients with seizures in the ED:

• Patients with seizure disorders are common in the ED and require prompt evaluation and treatment 5
• Advanced care, including intravenous access, laboratory work, cardiac monitoring, or oxygen administration, may be necessary for patients with seizures 5
• Antiepileptic drugs may be given to patients with seizures, and the choice of medication will depend on the patient's medical history and the characteristics of the seizures 5, 6, 3, 4
• Status epilepticus is a life-threatening condition that requires immediate attention and treatment 5