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

Official 2024 guideline from the American College of Emergency Physicians.

These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.

Strength

Recommendations

Anti-Epileptic Drugs (AEDs) for First-Time Seizure

Level C

Emergency physicians need not initiate antiepileptic medication* in the emergency department for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.

*Antiepileptic medication refers to medications prescribed for seizure prevention.

Level C

Emergency physicians need not initiate antiepileptic medication* in the emergency department for patients who have had a first unprovoked seizure without evidence of brain disease or injury.

*Antiepileptic medication refers to medications prescribed for seizure prevention.

Level C

Emergency physicians may initiate antiepileptic medication* in the emergency department, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.

*Antiepileptic medication refers to medications prescribed for seizure prevention.

Refractory Seizures

Level A

Emergency physicians should treat seizures refractory to appropriately dosed benzodiazepines with a second-line agent. Fosphenytoin, levetiracetam, or valproate may be used with similar efficacy.

Disposition

Level C

Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the emergency department.

AED Route of Administration

Level C

When resuming antiepileptic medication in the emergency department is deemed appropriate, the emergency physician may administer intravenous (IV) or oral medication at their discretion.

Literature

Original/Primary Reference

Huff JS, Melnick ER, Tomaszewski CA, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures. Ann Emerg Med. 2014;63(4):437-4

Other References

Smith MD, Sampson CS, et al. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Seizures: Approved by the ACEP Board of Directors, April 17, 2024. Ann Emerg Med. 2024;84(1):e1-e12.

Summary By

Eric Steinberg, DO, MEHP

What do the ratings mean?

Level A

Generally accepted principles for patient care that reflect a high degree of clinical certainty (ie, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).

Level B

Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (ie, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).

Level C

Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.