Management of Seizures in ED

Management of Seizures in ED from Sun YaiCheng

 

ACEP Clinical Policy

Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures

Ann Emerg Med. 2014;63:437-447

This clinical policy from the ACEP is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the ED to help clinicians answer the following critical questions:

1. In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?

• 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. (Level C)
  
• 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. (Level C)
  
• 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. (Level C)

2. 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?

• Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED. (Level C)

3. 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?

• When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion. (Level C)

4. 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?

• Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level A)
• Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level B)
• Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines. (Level C)

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【摘要】

ACEP Policy: Management of Seizures in ED 

• 第一次seizure 的急診就醫病患，不需要給予預防性的抗癲癇藥物 

• 第一次seizure 的急診就醫病患，若 CBC、血糖、腎功能、電解質、鈣離子、心電圖、CT (若符合適應症) 皆正常，病人意識完全恢復平常水準，無神經學症狀，生命徵象正常，有可信任的照護者，衛教勿騎車駕駛後，可急診出院門診追蹤 

• Status epilepticus 若使用 BZD 無效，可給予 dilantin, cerebyx, depakine (level B) or keppra, propofol, barbiturate (level C)，並同時尋找可能誘發癲癇的原因﹝電解質異常 (血糖、血鈉...)、缺氧、藥物毒性/戒斷、感染、中風...﹞