Six
Clinical Questions Conclusions
References
ACEP
Clinical Policy and Development:
2004 Seizure Patient Clinical Policy
Introduction
Emergency physicians frequently treat seizure and status epilepticus
(SE) patients in the Emergency Department (ED). In order to improve
the care of these patients, the American College of Emergency Physicians
(ACEP) recently published an ED seizure clinical policy that utilized
six critical clinical questions.1 Three of the questions address the
diagnosis, management, and disposition of new-onset seizure patients
in the ED. The remaining three questions address phenytoin loading,
anti-epileptic drug (AED) therapies in ED seizure patients who are refractory
to initial benzodiazepine and phenytoin therapies, and the indications
for urgent EEG monitoring. These questions and their corresponding recommendations
are designed to allow emergency physicians to better understand what
options exist in managing ED seizure patients optimally.
ACEP Clinical Policies: A Primer
Clinical policies are designed to distinguish evidence-based practice
from opinion-based practice, and as such they have the potential to
improve clinical decision-making, enhance medical education, and reduce
medical liability. These guidelines also have the potential to optimize
health care by providing consistency as patients are diagnosed and treated.
Furthermore, clinical policies have the capacity to improve resource
utilization, minimize cost, and help to identify areas in need of future
research.
The ACEP clinical policies committee was formed in 1987. Following initial
consultation with Dr. David Eddy, the grandfather of the clinical policy
movement in this country, ACEP’s clinical policy development utilized
a formal consensus approach by a panel of emergency physicians representing
different regions of the country. Using insurance claim data to identify
ED chief complaints that were either frequently seen, high risk, or
costly, a symptom-based policy process was established. The first ACEP
clinical policy on chest pain was published in 1991. This consensus
approach reflected the committee member’s best guess as to what
they thought best practice should be when managing chest pain patients
in the ED. This first clinical policy was, however, potentially biased,
given that it lacked a defined analytic procedure for incorporating
the relevant medical literature. The first clinical policy on seizures,
which was published in 1993, also did not fully integrate a systematic
approach in evaluating what the medical literature tells us is a best
clinical practice.2 As more clinical policies have been developed, including
the revision of the seizure clinical policy in 1997, the clinical policies
committee has moved toward a more evidence-based process for their development,
including standards for the evaluation and integration of published
clinical studies into the formal policy recommendations.
Clinical
Policy Committee Methodology
The clinical policy committee develops questions that are relevant to
a specific disease state or area within Emergency Medicine. A subcommittee
is then formed that includes members of the clinical policy committee
as well as experts in the clinical area being addressed by the clinical
policy. Relevant clinical studies from the medical literature are then
selected, reviewed and then graded using predetermined criteria.
Class I studies have utilized optimal randomized, controlled research
design methodology, and provide data that supports Level A recommendations,
those with the highest degree of clinical certainty. Class II studies
are more often non-randomized, but have utilized methods that allow
Level B recommendations to be made, those that reflect moderate clinical
certainty. Class III studies, which include case series as well as consensus
documents, allow the generation of Level C recommendations, which reflect
treatment strategies that are to be considered given their possible,
but not clearly proven, effectiveness. For all of the reviewed articles,
there is a process by which the article can be downgraded based on design
flaws, causing the corresponding recommendation level also to be reduced.
Of note is the fact that these ACEP clinical policies are to be applied
only to hospital-based emergency physicians.
The
ACEP Seizure Clinical Policies
The initial 1993 ACEP seizure clinical policy focused on the evaluation
and treatment of known alcohol-related seizures. A consensus approach
emphasized the initial stabilization of patients with life-threatening
seizures, including oxygenation and airway control, hypoglycemia identification
and treatment, and clinical observation. Little guidance was offered
to clinicians, but the consensus document did support a diagnostic evaluation
based on vital signs, physical examination, and a neurological examination
designed to detect focal deficits. This policy did not require extensive
diagnostic studies as part of the treatment paradigm. The 1997 revision
of this seizure clinical policy used a more formal consensus approach
and a systematic literature review. This policy also expanded the seizure
guideline to include patients with known seizure disorders.
The 2004 revision of the ACEP seizure clinical policy was based fully
on an evidence-based approach as it answers six clinically relevant
questions regarding the treatment of seizure and SE patients in the
ED. A computerized search was completed to identify pertinent medical
literature and references related to acute management of patients with
seizures. The articles were then graded according to their methodology,
size, potential biases, and the reliability of the data collection and
analysis. Finally, in order to validate committee conclusions and make
their application more robust, the seizure clinical policy was submitted
to selected experts and relevant specialty societies for peer review
and revision prior to its final publication in May 2004.
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Six
Clinical Questions from the 2004 ACEP Seizure Clinical Policy
The following
six questions are addressed in the ACEP seizure clinical policy. Three
questions address issues related to patients who present with new-onset
seizures, and three address other issues related to the diagnosis and
treatment of patients who present with seizures or are in status epilepticus.
Question 1: What laboratory tests are indicated in the otherwise
healthy adult patient with a new-onset seizure who has returned to a
normal baseline neurological status?
Level B Recommendations:
1. 1. Determine a serum glucose and sodium level on patients with a
first time seizure with no comorbidities who have returned to their
baseline.
2. 2. Obtain a pregnancy test if a woman is of childbearing age.
3. 3. Perform a lumbar puncture, after a head CT, either in the ED or
after admission, on patients who are immuno-compromised.
When examining
the necessity of doing laboratory testing in new-onset seizure patients,
the committee attempted to focus on which tests are likely to be abnormal
and require some specific acute therapy. Based on studies that examined
series of patients who received laboratory tests following a new-onset
seizure, the level B recommendations suggest that only routine chemistry
testing may be useful, given that hypoglycemia and hyponatremia both
can cause seizures to occur. The literature also supports that testing
for CNS infection, including CT examination and lumbar puncture, should
be considered in the work-up of patients who are immuno-compromised.
Of note, however, is the fact that these latter tests for CNS infection
need not necessarily be completed prior to hospital admission if the
clinical situation precludes their completion.
Question 2: Which new-onset seizure patients who have returned
to a normal baseline require a head computed tomography (CT) scan in
the emergency department (ED)?
Level B Recommendations:
1. 1. When feasible, perform neuroimaging of the brain in the ED on
patients with a first time seizure.
2. 2. Deferred outpatient neuroimaging may be used when reliable follow-up
is available.
As was the case
with the need for laboratory testing, the committee attempted to determine
if neuroimaging needed to be completed given the frequency with which
patients with a normal neurological exam would have a CT abnormality
that required emergent or urgent intervention. Again, based on data
from series that included the results of neuroimaging in new-onset seizure
patients, it is recommended that emergency physicians complete a CT
scan in the ED when feasible, but that it could be deferred if outpatient
testing could be reasonably assured in a timely manner.
Question 3: Which new-onset seizure patients who have returned to a
normal baseline need to be admitted to the hospital and/or started on
an antiepileptic drug?
Level C Recommendations:
1. 1. Patients with a normal neurological examination can be discharged
from the ED with outpatient follow-up.
2. 2. Patients with a normal neurological examination, no comorbidities,
and no known structural brain disease do not need to be started on an
antiepileptic drug in the ED.
This question
addressed an important situation that occurs frequently in every day
practice. The purpose of admitting new-onset seizure patients and/or
starting them on an anti-epileptic drug (AED) is to prevent these patients
from going into status epilepticus (SE) soon after the occurrence of
the new-onset seizure. Unfortunately, there is no good epidemiological
data that documents the frequency with which new-onset seizure patients
will have a recurrent seizure or develop SE soon after their initial
ED evaluation. Studies suggest that the rate of recurrent seizures and
SE is sufficiently low that it may not be necessary to admit seizure
patients for observation or treat them with an AED if they have a normal
mental status. As such, those new-onset seizure patients who are at
the lowest risk for a seizure recurrence or developing SE can be considered
for discharge without starting an AED based on the level C recommendations
contained in this clinical policy.
Questions 4: What are effective fosphenytoin or phenytoin dosing
strategies for preventing seizure recurrence in patients who present
to the ED after having had a seizure with a subtherapeutic serum phenytoin
level?
Level C Recommendation:
Administer an intravenous or oral loading dose of phenytoin or intravenous
or intramuscular fosphenytoin, and restart daily oral maintenance dosing.
This clinical question addresses a clinical scenario that is frequently
encountered in the ED. Commonly, seizure patients are brought to the
ED because of a seizure that is related to non-compliance with oral
phenytoin maintenance therapy. The goal of phenytoin loading is to provide
a therapeutic level in a safe, expedient, and cost-effective manner.
Oral loading, while quick and efficient, could be associated with more
frequent seizure recurrence if therapeutic levels are achieved in a
delayed or inconsistent manner. Parenteral phenytoin or fosphenytoin
loading can be less efficient than oral loading in the ED, but the parenteral
route, because it achieves a therapeutic phenytoin level most consistently,
could reduce the risk of a recurrent seizure or SE. Because all of the
above strategies have been found to be safe and effective in various
studies, the committee provided a level C recommendation that a loading
dose of phenytoin (intravenous or oral) or fosphenytoin (intravenous
or intramuscular) could be completed in the ED prior to starting daily
oral maintenance after ED discharge.
Question 5: What agent(s) should be administered to a patient
in status epilepticus who continues to seize after having received a
benzodiazepine and a phenytoin?
Level C Recommendation:
Administer one of the following agents intravenously; “high dose
phenytoin”, phenobarbital, valproic acid, midazolam infusion,
pentobarbital infusion, or propofol infusion.
The ACEP policy committee considered the situation in which a patient
fails to respond to initial treatment with a benzodiazepine or a phenytoin,
and is considered to be in SE. There exist few randomized studies that
address the optimal management of SE patients; instead, there are only
case series that suggest that different therapies can be effective in
treating patients who fail to respond to these two classes of AEDs.
Although there are clinical situations in which each individual therapy
may be superior to another in terminating a prolonged seizure, there
is no data that suggests that any one therapy is uniformly superior
to another. As such, there exists only a Grade III recommendation that
one of the following agents be administered intravenously: “high-dose
phenytoin” (fosphenytoin or phenytoin at 30 mg/kg), phenobarbital,
or valproic acid, or infusions of midazolam, pentobarbital, or propofol.
Question 6: When should electroencephalographic (EEG) testing
be performed in the emergency department?
Level C Recommendation: Consider an emergent EEG in patients suspected
of being in non-convulsive status epilepticus or in subtle convulsive
status epilepticus; patients who have received a long acting paralytic,
or patients who are in a drug-induced coma.
When considering this question, the committee understood that EEG testing
is infrequently obtained in the ED, in part because it is not often
clinically indicated, and also because it is not offered on a 24/7 basis
in most institutions. Despite the fact that EEG monitoring is not frequently
requested by emergency physicians, it is still important to know when
it should be ordered either as a stat ED test or upon ICU arrival. There
are two clinical situations identified in the committee’s level
C recommendation when EEG monitoring should be considered. The first
is when non-convulsive or subtle SE is possible because of a prolonged
comatose state. The second is when it is no longer possible to determine
if a seizure is occurring clinically, either because the patient has
received a paralytic prior to rapid sequence intubation or because the
patient is in an induced coma. The goal in this situation is to order
an EEG when it is possible that electrical seizure activity requires
additional AED therapy despite the absence of clinically apparent motor
seizure activity.
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Conclusion
In developing the recommendations for these six clinically important
questions, the ACEP clinical policy committee attempted to improve the
care of patients with seizures and SE in the ED. It is interesting to
note that despite the publication of thousands of studies related to
seizures and SE, the literature only supports level B recommendations
for the laboratory and neuroimaging of new onset seizures, and that
the other four questions could only be supported by level C recommendations.
This suggests that emergency physicians must be aware of their options
when treating these patients, and that the care of each patient be individualized
in order to maximize the chance of having a good outcome.
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References
1. ACEP Clinical Policies Committee,
Clinical Policies Subcommittee on Seizures. Clinical policy: Critical
issues in the evaluation and management of adult patients presenting
to the emergency department with seizures. Ann Emerg Med. 2004;43:605-625.
2. Epilepsy Foundation of America. Treatment of convulsive status epilepticus.
Recommendations of the Working Group on Status Epilepticus. JAMA. 1993;18:854-859.
This
material is derived from “Calming the Storm: Seizures and Status
Epilepticus in the Emergency Department,” a supplement to ACEP
News, Vol 24., No. 2, February 2005, published by Elsevier Inc. Used
with permission.
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