Seizures In Adults, Part 1

March 23, 2017
Does your emergency practice seem to care for adult patients with seizures every shift? Some basic questions we often face with seizure patients are:
  • Should you start first time seizure patients on medical therapy?
  • Should you admit a first time seizure patient?
  • For a known seizure patient, does the route of administration of anti-seizure medication impact the recurrence rate?
The American College of Emergency Physicians (ACEP) issues clinical policies that answer specific clinical questions, rating the evidence and the strength of the recommendation.  Although these are not meant to establish a standard of care, you can feel very comfortable practicing in accordance with these recommendations.  The recommendations discussed below pertain to adult patients.

Provoked vs. Unprovoked Seizures

To understand ACEP’s seizure recommendations, you need to be familiar with the terms provoked vs. unprovoked seizures.

  • Provoked seizures are those caused by a specific medical condition such as trauma, infection, tumor, electrolyte disturbance, withdrawal, etc.
  • Unprovoked seizures are those that have no apparent cause.
First, the EP must determine if the seizure is provoked or unprovoked.  If provoked, the EP should treat the precipitating medical condition but need not initiate anti-epileptic treatment (ACEP recommendation level C) except for persistent seizure activity.

Unprovoked Seizure Recommendations

The following ACEP recommendations pertain to the first occurrence of an unprovoked seizure in an adult:

Workup:

ACEP addressed the workup of a first time unprovoked seizure in 2004 (see link below). That policy recommended that at least the following be performed:

  • glucose and sodium levels
  • pregnancy test (if appropriate)
  • cranial imaging (can be deferred if there is reliable follow up)
  • LP for immunocompromised patients to rule out infection.

Medication:

This year, ACEP addressed a few more of these questions, including whether anti-epileptic medication should be initiated following a first unprovoked seizure.  The recommendations (level C) for adults are:

  • For a first time unprovoked seizure, EPs need not initiate anti-epileptic medication in the ED.
  • For a first time unprovoked seizure with a remote history of brain disease or brain injury, EPs may initiate medication or defer treatment.
Here is some info that may be useful in deciding the treatment plan and communicating with your patients:
  • Up to 50% of patients with a first unprovoked seizure will have a recurrent seizure within 5 years.
  • One would have to treat 14 patients to prevent a single seizure recurrence within 2 years.
  • Starting treatment for a second unprovoked seizure is a reasonable strategy (and one that I typically follow).
  • Patients with a past history of brain injury, such as trauma or stroke, have an increased rate of recurrence, so it would be appropriate to initiate treatment after the first seizure in these patients.

Disposition (admit or not):

Regarding whether or not to admit the adult patient with a first-time unprovoked seizure, the ACEP recommendation (level C) is:

  • EPs need not admit patients with a first unprovoked seizure.

Known Seizure Disorder – Route of Mediation Administration

The clinical policy also provides useful guidance regarding the route of medication administration in adult patients with a known seizure disorder.
  • The EP may administer IV or oral medication at their discretion.

This final recommendation is valuable in terms of saving time and resources by providing oral loading, rather than parenteral, for patients with sub-therapeutic levels of anti-epileptic medication.

Conclusion

In conclusion, ACEP’s policies regarding the treatment of adult patients with first time or known seizures are rather simple:

New seizures:  Search for a treatable cause, such as hypoglycemia, hyponatremia, infection, alcohol withdrawal, or a structural lesion in the brain.  If none is found, you need not initiate anti-epileptic medication treatment, and need not admit the patient to the hospital.  Outpatient referral is appropriate.

Recurrent seizures:  There is no evidence to support loading medication by the parenteral route, rather than orally.

Stay tuned for more information on treating ongoing seizure activity and for guidance on loading various anti-epileptic medications.

The ACEP clinical policies on managing seizures in the ED can be found here: ACEP Seizures 2004 and ACEP Seizures 2014

Read part 2 about Seizures in Adults – Status Epilepticus.

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