clinical policy for the initial approach to patients

C L I N I C A L P O L I C Y

Clinical Policy for the Initial Approach to

Patients Presenting With a Chief Complaint

of Seizure Who Are Not in Status Epilepticus

INs clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Seizure.

Members of the Clinical Policies Committee included:

Earl g Smith, III, MD (Chair I992-1995, Co-Chair 1995-i996)

Stephen V Cantrill, MD (Co-Chair 1995-1996, Chair 1996-1997)

Melocly Campbell, RN, MSN, CEN, CCRN (ENA Representative 1996-1997)

Stephen A Coluccidlo, MD

William C Dalsey, MD

Francis M Fesmire, MD

F_John Gallagher, MD

AMy S Jagoda, MD

Stephen Karas, Jr, MD

Dineke Mackey, RN, MN, CEN (ENA Representative 199I-1995)

Barbara A Murphy, MD

Michael P Pietrzak, MD

Daniel G Sayers, MD

Members of the Clinical Policies Subcommittee on Seizure included:

Francis M Fesmire, MD (Chair)

E John Gallagher, MD

Philip L Henneman, MD

Andy S Jagoda, M D

Staff Liaison, Clinical Policies Committee: Rhonda Whitson, RRA

Approved by the ACEP Board of Directors, January 13, •997

Copyright © by the American College of Emergency Physicians

[American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg MedMay 1997;29:706-724.]

PREFACE

This clinical policy is a scheduled revision of the original seizure policy published in May 1993. The topic considered here, the initial approach to seizures, was selected for three reasons: (1) seizures are common, complex, clinical problems; (2) individuals who suffer from seizures frequently seek emergency care; and (3) timely, thoughtful diagnostic and therapeutic intervention may have a substantial impact on both short- and long-term morbidity.

This clinical policy was created after a careful review and critical analysis of the peer-reviewed literature. All publications were stratified into one of three categories, contingent on the quality of the methodology, the strength of the evidence presented, and the validity of the inferences drawn from that evidence.

This clinical policy stresses four concepts: (1) prolonged altered mental status following a seizure should not be attributed to an uncomplicated postictal state; (2) patients with previously diagnosed epilepsy who are awake and alert following a typical convulsion require little diagnostic workup other than a thorough history and consideration of measurement of antiepileptic drug levels; (3) patients with alcohol-related seizures require careful assessment targeted at identifying underlying or comorbid conditions; (4) although the handling of driver's license privileges for people with epilepsy is controversial and differs from region to region, ACEP suggests that emergency physicians under- stand the law in their state and tell their patients not to drive or operate machinery until they see their continuing care providers.

The reasons for developing clinical policies in emergency medicine and the approaches used in their development have been enumerated. A This policy is a product of the

7 0 6 ANNALS OF EMERGENCY MEDICINE 29:5 MAY 1997

ACEP CLINICAL IPOLICY

ACEP clinical policy development process, including expert review and field testing, and is based on the existing literature; where literature was not available, consensus of emergency physicians was used. Expert reviewers included emergency physicians, physicians from other specialties such as neurolog3~, and various specialty societies. Comments were received from members of the American Academy of Neurology, the American Association of Neurological Sur- geons, the American Epilepsy Society, the Internal Medicine Center to Advance Research and Education (IMCARE) Prac- tice Guidelines Network, the Emergency Nurses Association, the American Academy of Family Physicians, the American Society of Emergency Radiology, and the Practice Committee of the Child Neurology Society Their responses were used to further refine and enhance this policy. Field testing was conducted in EDs differing in locale, size, and resources. The field testing experience resulted in additional refine- ments to the policy ASchriger DL, Cantrill SV, Green CS: The origins, benefits, harms, and implications of emergency medicine clinical policies. A~n Emery Mef11993;22:597-602.

Inclusion Criteria: This policy is intended for use with patients 6 years or older who have had a seizure and are not in status epilepticus.

Exclusion Criteria: This policy is not intended for use with patients in whom seizure is due to eclampsia or to acute head trauma.

The treatment of patients with alterations in mental status that are not clearfy attributable to their postictal state should reflect consideration of the full differential diagnosis of altered mental status and should include appropriate treatment for reversible conditions when indicated. This policy is not intended for use in the care of such patients. Similarly, this policy is not intended for patients who have had a seizure secondary to a syncopal episode; the care of these patients must address the differential diagnosis of that phe- nomenon. Care should be taken to differentiate between seizures that occur as the result of a primary neurologic process and those that are secondary to underlying problems. The management of seizures of the latter type, such as those that may be due 1:o hypotension, hypoxia, bradycardia, or systemic drug toxicity, should be directed at the primary problem and will therefore diverge from the rules and guidelines set forth in this policy

Stabilization: This policy assumes that life-threatening emergencies (apnea, hypoxia, hypotension) have been treated or stabilized and is not meant to apply to the unstable patient. If a patient presents in an unstable condition, initial resuscitation and stabilization must take precedence.

Rationale: This policy is based on the scientific literature where possible. When insufficient data were found after review of published research literature, review articles, and standard texts, a consensus process was used. A review of the literature on seizures revealed several general concepts that are reflected in this policy These are:

The "standard" workup of first seizures is controversial. New onset seizure results from a multitude of causes and may be a sign of a serious disease process. Tumors, strokes, mira- cranial hemorrhage, central nervous system (CNS) infec- tions, metabolic derangements, dysrhythmias, and drug and alcohol abuse, each may induce a first seizure. Neuroimaging is generally performed as part of the evaluation of a first seizure. Whether this procedure is performed as part of the initial ED evaluation or later on an outpatient basts is a function of clinical presentation, availability of neuroimaging, and local custom. A noncontrast computed tomography (CT) is the recommended modality for patients with a seizure who require emergent neuroimaging in the ED because it (1) will identify most cases of intracranial Needing, edema, and mass effect and (2) is widely available in an emergency setting (in contrast to magnetic resonance imaging [MRI]). Use of noncontrast CT as the primary imaging modality does not preclude obtaining a subsequent contrast CT. In fact, in HIV positive patients this is strongly encouraged. Similarly, MRI may be obtained, if available, although this is often done in consultation with a neurologist, neurosurgeon, or radiologist.

Throughout this policy CT is recommended before lumbar puncture (LP) in cases where increased intracranial pressure or bleed is suspected. LP may be performed without a prior CT if there is no clinical evidence of increased intracranial pressure such as altered mental status, focal neurologic deficit, or papilledema. Whenever bacterial meningitis is suspected, antibiotic administration should not be delayed pending performance of CT or LP

Retrospective studies indicate that the yield of abnormal serum glucose and electrolytes (serum sodium) in the evaluation of first seizure is high enough to justify recommend- ing their routine measurement. 39,sl Routine renal function tests, calcium and magnesium determinations, CBC, urine drug screens, and arterial blood gases are of uncertain value in patients in whom mental stems and physical examination findings are completely normal. It is hoped that future large prospective studies will clarify some of these issues.

Patients with previously diagnosed epilepsy who are taking antiepileptic drugs and who have had a typical seizure frequently require only a measurement of the serum antiepileptic drug levels unless the history and physical examination dictate otherwise. It is important that the physician

M A Y 1997 29:5 ANNALS OF EMERGENCY MEDICINE 7 O7

ACEP CLINICAL POLICY

recognize that epilepsy is a chronic disease. It is essential that these patients be provided appropriate follow-up care.

Alcoholics can have a seizure as a result of alcohol intake, as a result of abstinence, as the result of an underlying seizure disorder, or as a result of complications of their alcoholism. It is imperative that abnormalities found on physical or neurologic examination of such patients be investigated to rule out those conditions (eg, subdural hematoma, electrolyte abnormalities) for which alcoholics are at risk.

Although the policy has several rules regarding documentation of the history, it is recognized that certain patients will be unable to provide such history and that collateral historians may not be available. In this case the physician should document that the patient cannot provide a history or its equivalent on the medical record.

Strength of Evidence of References - The Committee has developed a strength of evidence rating criteria of the references as follows:

Strength of evidence A - Includes randomized controlled trials, observational prospective cohort studies, and meta- analysis of randomized controlled studies. For a study to receive an A rating, it must have adequate power to detect a clinically important difference or sufficiently narrow confidence interval limits to exclude a difference.

Strength of evidence B - Includes retrospective cohort studies, observational case controlled studies, and other metaanalyses.

Strength of evidence C - Includes cross-sectional studies, correlational studies, case series and case reports, and published panel consensus by acknowledged group of experts.

Strength of Evidence Supporting Rules - The Com- mittee has rated all Rules appearing in this policy as follows:

I = Strong research-based evidence (multiple relevant and high-quality studies, including at least one class A study);

II = Moderate research-based evidence (multiple relevant class B studies);

III= Limited research-based evidence; IV= Panel consensus of evidence not meeting inclusion

criteria for research-based evidence. If a rating does not appear after a rule, the recommended

action is based on panel consensus of evidence not meeting inclusion criteria for research-based evidence (IV rating).

Implementing the Policy: The rules and guidelines for patient management emphasize those findings with the potential for high risk to the patient. Some actions are separated by a slash mark (/), meaning that either may be appropriate in a given clinical situation; the action is at the discretion of the clinician. The order m which items appear in the rules and guidelines is arbitrary and not meant to

imply the order in which they should be performed. In using this clinical policy it may be helpful to think of the Redes as broad categories that should be recorded as pertinent posi- tives or negatives and Guidelines as detailed or expanded lists that are meant to prompt the physician to consider many possibilities. All therapeutic modafities have contra- indications, and in these situations the rules of the policy do not apply. It is important that all data from pertinent aspects of the history, physical examination, and results of diagnostics studies be collected and that no single finding be considered independently. Premature closure on a diagnosis can lead to inaccuracy. Documentation should be sufficient to reflect the clinical decision-making process. It is unrealistic to expect a physician to perform or document every item in the guidelines for any individual patient.

Beyond recommendations to admit, this policy is inten- tionally nondirective with regard to the specific nature of patient disposition (eg, admission to monitored inpatient bed, unmonitored inpatient bed, or observation unit). Be- cause different institutions have different resources and capabilities in the management of these patients, the recom- mendation to admit a patient (or to obtain a specific consultation) may require transfer of the patient to an institution better able to deal with the patient's specific needs. The action "consult" means to discuss by phone or in person with a provider of specialty care.



RULE* GUIDELINE~

Solicit and record a history that includes:

Seizure history

Medications

Medical history

Consider these aspects of the history:

Type and etiology, baseline frequency, change in frequency or type, duration, circumstances, incontinence, aura and other associated symptoms, description of seizure and postictal state, loss of consciousness, previous workup, source of regular care

Pain or injury resulting from this seizure

Exacerbants: noncompliance with seizure medication(s), recent infection, sleep deprivation, alcohol/drug/toxin history, pregnancy

Antiepileptic drugs (dosage, compliance, recent changes), other medications (recent changes, oral hypoglycemics/ insulin, anticoagulants, drug interactions)

Allergies, head trauma, recent headaches, fever, abnormal motor movements, numbness or focal weakness, menstrual history, diabetes, cancer, heart disease, existing neurologic disorders, electrolyte imbalance, immune suppression, parasitic infection, CNS infection, psychiatric history, family history, HIV risk factors

"Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing, inability to comply with rules should be incorporated in institutional policies. tGuidelige: An action that rnay he considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to fellow a guideline is improper.

MAY 1997 29:5 ANNALS OF EMERGENCY MEDICINE 7 O 9


RULE* GUIDELINE t

Conduct and record a physical examination that includes:

Vital signs: blood pressure, pulse, respirations, temperature

Neurologic

Mental status

Consider these aspects of the physical examination:

General appearance

Head: evidence of trauma, pupils, fundi, tympanic membranes, intraoral trauma

Spine: bony tenderness, meningismus

Heart: rhythm, murmurs

Lung: breath sounds

Lymphatic: lymphadenopathy

Skin: jaundice, color, cyanosis, evidence of drug abuse, alcoholism, coagulopathy

Extremities: range of motion of shoulders, evidence of trauma

Cranial nerves, strength, gait, coordination, reflexes, Babinski sign (dorsiflexion reflex)

Level of consciousness

Content of consciousness: orientation, memory, cognitive function

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies. tGuideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to follow a guideline is improper.

7 1 O ANNALS OF EMERGENCY MEDICINE 29:5 MAY 1997


Implement ACTIONS based on the FINDINGS for the following VARIABLES: i

VARIABLE FINDING ACTION

History

Seizure history

Circumstances

Exacerbants (including medications that alter antiepileptic drug metabolism and lowers seizure threshold)

Medications

Medical history

Known epileptic

Epileptic with new seizure type or pattern or no previous workup

No previous seizure

Potential deceleration injury secondary to seizure

Drug/toxins/occupational exposures

Ethanol use

Patient taking antiepileptic drugs

Patient taking oral hyp oglycemics/insulin

Patient taking anticoagulants

Recent head trauma

Diabetes

Heart disease

Coagulopathy/platelet disorder

History of electrolyte abnormalities

History of renal failure

No recent menses in patient with reproductive potential

Rule*

Seek etiology/exacerbants

Evaluate as first seizure

Gluose determination

Guideline t

Seek exacerbants Antiepileptic drug levels

Evaluate as first seizure Antiepileptic drug levels

C-spine immobilization C-spine x-ray

Toxicologic screen/levels

Glucose determination

Antiepileptic drug levels

Administer dextrose

Coagulation studies Noncontrast head CT

Noncontrast head CT

Glucose determination

Cardiac monitor ECG

CBC Coagulation studies Noncontrast head CT Treat coagulopathy

Electrolytes

Electrolytes BUN/crcatinine

Pregnancy test

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing, inability to comply with rules should be incorporated in institutional policies. *Guideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to follow a guideline is improper.

MAY 1997 29:5 ANKALS OF EMERGENCY MEDICINE 7 I 1


Implement ACTIONS based on the FINDINGS for the following VARIABLES:


History

Medical history-- continued

Physical Examination

Vital signs

Head

2nd half of pregnancy

HIV positive/ immunosuppression

Alcoholism

Temperature elevation

Abnormal respirations

Bradycardia/tachycardia/ irregular pulse

Signs of recent trauma

Rule* Guideline t

Assess blood pressure, deep tendon reflexes, urine protein

Assess fetal status Consult obstetrician

CBC MRI or CT (with and

without contrast) Lumbar puncture (LP) ~

if not contraindicated by neuroimaging studies

Electrolytes/magnesium level

BUN/creatinine Glucose determination Toxicologic screen Alcohol level CBC Platelets Prothrombin time Noncontrast head CT Thiamine administration Magnesium administration

Drug screen LP Antibiotics Manage temperature

Supplemental oxygen ABG/pulse oximetry

Cardiac monitor ECG

Noncontrast head CT

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot he followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies. tGuideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to fellow a guideline is improper. ~For purposes af this policy unless otherwise specified, lumbar puncture implies cerebrospinal fluid (CSF) analysis for glucose, protein, cell count, spun Gram stain, and culture and sensitivity. Additional studies for other organisms, such as cryptococcus and tuberculosis may be indicated in certain patient populations.



Implement ACTIONS based on the FINDINGS for the following VARIABLES


Physical examination

Neck

Neurologic examination

New focal abnormality

Cervical spine tenderness

Stiff neck on flexion

Mental status not at baseline but improving

Mental status not at baseline and not improving

Rule*

Observe Reexamine

IV access Oxygen/pulse oximetry Electrolytes, glucose level

[H] Rapid glucose

determination/administer dextrose

Noncontrast head CT [II] Observe Reexamine

IV access Noncontrast head CT [II] Observe Reexamine Consult/admit

Guideline t

C-spine immobilization C-spine x-ray

Blood culture Noncontrast head CT LP Antibiotics

IV access

Rectal temperature Cardiac monitor ABG/carboxyhemoglobin Calcium, magnesium

levels BUN/creatinine Toxicologic screen/levels Alcohol level CBC Urinalysis EEG ECG LP Opiate antagonist Thiamine administration Magnesium administration Consult/admit

Supplemental oxygen Oximetry Electrolytes Calcium BUN/creatinine Toxicologic screen CBC LP

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies. *Guideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guiderines are not always follewed, and there is no implication that failure to follow a guideline is improper.

MAY 1987 29:5 ANNALS OF EMERGENCY MEDICINE 7 1 3


VARIABLE

Implement ACTIONS for the following VARIABLES

ACTION

Assessment

First seizure without known etiology or previously diagnosed seizure with change in pattern without attributable cause

With mental status returning to baseline

With mental status not returning to baseline

Rule* Guideline t

Evaluate for pregnancy [III] 18,48,78

Serum sodium level [II] Glucose determination

[U]

Noncontrast head CT or schedule neuroimaging # [n]

Provide referral for follow-up care or admit

Reexamine IV access Oxygen/pulse oximetry/

ABG Evaluate for pregnancy

[III] ~8,48,78

Electrolytes Glucose determination/

administer dextrose Noncontrast CT Observe/admit

Oxygen/pulse oximetry Cardiac monitor Electrolytes Calcium level BUN/creatinine Toxicologic screen CBC RPR HIV testing Urinalysis EEG LP Antiepileptic drug Glucose Consuh

Rectal temperature Cardiac monitor ABG/carboxyhemoglobin Calcium, magnesium

levels BUN/creatinine Toxicologic screen/levels Alcohol level CBC Urinalysis EEG ECG LP Opiate antagonist Thiamine administration Magnesium administration Consult/admit

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not er cannel be followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies. *Guideline: An action that may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to follow a guideline is improper. #For patients with first time seizure: Emergent neuroimeging should be performed when any of the following are present: partial-onset (focal) seizure, focal neurologic deficit, persistent altered mental status (with or without intoxication), fever without known source, recent trauma, persistent headache, history of cancer, history of anticeagolation, suspicion of AIDS, or unreliable follow-up. "Schedule neuroimaging" may imply referring the patient to the primary care provider for actual procedure scheduling>

7 I 4 ANNALS OF EMERGENCY MEDICINE 29:5 MAY 1997


VARIABLE

Implement ACTIONS for the following VARIABLES:

ACTION

Assessment

Previously diagnosed epilepsy

Alcohol-related seizure that is not a first seizure

Drug/toxin related seizure that is not a first seizure

Disposition

Admission

Transfer

Discharge

Rule*

Observe Manage antiepileptic drug

levels Provide referral for

follow-up care

Observe Provide referral for

follow-up care (for seizure)

Observe Provide referral for

follow-up care

Transfer care to accepting physician

Follow ACEP and other applicable transfer policies "~

Provide referral for follow-up care

Provide instructions regarding treatment and circumstances that require return to ED

Guideline t

Evaluate compliance Evaluate for drug

interaction Discuss any change in

dosing with primary care physician

Electrolytes, magnesium level

Rapid blood glucose determination or administer dextrose

CBC Thiamine administration Magnesium administration Treat ethanol withdrawal Refer for drug abuse

rehabilitation

Decontamination* * Specific antidotes/

management Treat for drug toxicity/

withdrawal Refer for drug abuse

rehabilitation

*Rule: An action reflecting principles of good practice in most situations. There may be circumstances when a rule need not or cannot be followed; in these situations, it is advisable that deviation from the rule be justified in writing. Inability to comply with rules should be incorporated in institutional policies. tGuideline: An action tha: may be considered, depending on the patient, the circumstances, or other factors. Thus, guidelines are not always followed, and there is no implication that failure to follow a guideline is improper. **This may include the following: skin decontamination, gastric bvage, whole bowel irrigation, charcoal, cathartics.

MAY 1997 29:5 ANNALS OF EMERGENCY MEDJCINE 7 t 5


Table

GRADING OF STRENGTH OF PUBLISHED EVIDENCE 1

Strength of Evidence A

1) Interventional: Randomized controlled trials (RCTs) 2,3,4

2) Analytical observational: Prospective cohort studies 2

3) Aggregate: Metaanalyses of RCTs only 2

B

1) Analytical observational: Retrospective cohort studies 2

2) Analytical observational: Case control studies 2

3) Aggregate: Other metaanalyses a

C

1) Descriptive: Cross-sectional studies (including point prevalence) 5

2) Descriptive: Correlational studies 5

3) Descriptive: Case series and case reports

4) Consensual: Published panel consensus by acknowledged group of experts

This classification scheme is based on the fundamental assumption that there is no intrinsic bias in either the design or the execution of the study, and that the role of chance and confounding have been adjusted for in the data analysis te optimize internal validity. z Comparative studies, whether interventional or observational, that produce negative results must have adequate power (_>80%) to detect a clinically important difference if one were present or sufficiently narrow confidence interval limits that a clinically important difference between the two maneuvers under comparison can be reasonably excluded. 3 Independent of single, double, or unblinded status, unless lack of blinding introduces detection bias. 4 Includes RCTs with factorial design. 5 For descriptive studies, the confidence interval surrounding the point estimate must be sufficiently narrow that reasonable precision is obtained.


A C E P C L I N I C A L P O L I C Y

BIBLIOGRAPFIY

The following citations are not intended to be a compre- hensive review of the literature on seizure or a complete listing of all the works used in the development of this clinical policy. The purpose of this listing is to provide a sample of the kinds of documents that the Clinical Policies Committee reviewed during the development of this policy and to provide the reader with a general read- ing list. The strength of evidence is listed at the end of each reference. Please see the previous page for definitions of strength of e~ddence.

1. All&edge BK, Lowenstein DH, Simon RP: Placebo-controlled trial of intravenous dephenylhydantoin for short- term treatment of alcohol withdrawal seizures. Am d Med 1989;87:645-648. [A] 2. All&edge BK. Seizures associated with recreational drug abuse. Neurology 1989;39:1037-1039. [B] 3. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America: Consensus statements, sample statutory provisions, and model regu- lations regarding licensing and epilepsy. Epilepsia 1994;35:696-705. [C] 4. American College of Emergency Physicians: Appropriate interhospital patient transfer. Ann Emerg Med 1993;22:766-767. [C] 5. American College of Emergency Physicians, American Academy of Neurology, American Association of Neurological Surgeons, American Society of Neuroradiology: Practice parameter: Neuroimaging in the emergency patient presenting with seizure (summary statement). Ann Emerg Med 1996; 28:114-118. [B] 6. American College of Physicians: Magnetic resonance imaging of the brain and spine: A revised statement. Ann Intern Med 1994;120:872-875. [C] 7. Aminoff MJ, Scheinman MM, Griffin JC, et al: Electrocerebral accompaniments of syncope associated with malignant ventricular arrhythmias. Ann Intern Med 1988;108:791-796. [B] 8. Annegers JE Grabow JD, Groover RV, et al: Seizures after head trauma: A population study. Neurology 1980;30:683-689. [B] 9. Arieff AI, Llach E Massry SG: Neurological manifesta- tions and morbidity of hyponatremia: Correlation with brain water and electrolytes. Medicine 1976;55:121-129. [B] 10. Bag S, Behari M, Ahuja GK, et al: Pregnancy and epilepsy. ] Neurol 1989;236:311-313. [B] 11. Baraff LJ, Schriger DL, Starkman S: Compliance with a standard for the emergency department management of

epileptics who present after an uncomplicated convulsion. Ann Emerg Med 1990;19:367-372. [B] 12. Beauregard LA, Fabiszewski R, Black, et al: Combined ambulatory electroencephalographic and electrocardio- graphic recording for evaluation of syncope. Am J Cardiol 1991;68:1067-1072. [B] 13. Berg AT, Shinnar S: The risk of seizure recurrence following a first unprovoked seizure: A quantitative review. Neurology 1991;41:965-972. [B] 14. Bladin CF, Willmore J: Seizures after stroke. Stroke Clinical Updates 1994;5 (issue 2). [B] 15. Brodie MJ: Drug interactions in epilepsy. Epilepsia 1992;33 (suppl 1P):S13-$22. [C] 16. Cordingley G, Brown D, Dane P, et al: Increases in serum prolactin levels associated with syncopal attacks. Am d Emerg Med 1993;11:251-252. [B] 17. Cox RE: Hypoparathyroidism: An unusual cause of seizures. Ann Emerg Med I983;12:314-315. [C] 18. Dalessio D: Seizure disorders and pregnancy. N EnglJ Med 1984;312:559-563. [C] 19. Day SC, Cook EF, Funkenstein H, et al: Evaluation and outcome of emergency room patients with transient loss of consciousness. Amj Med 1982;73:15-23. [B] 20. Dhuna A, Pascual-Leone A, Langendorf F, et al: Epileptogenic properties of cocaine in humans. Neurotoxicology 1991; 12:621-626. [B] 21. Dohrmann ML, Cheitlin MD: Cardiogenic syncope: Seizures versus syncope. Netirol Clin 1986;4:549-561. [C] 22. Earnest MP, Feldman H, Marx JA, et al: Intracranial lesions shown by CT in 159 cases of first alcohol-related seizures. Neurology 1988;1561-1565. [B] 23. Edwards R: How often does a CSF pleocytosis follow generalized convulsions. Ann Neurol 1983;13:460. [C] 24. Eisner RF, Turnbull TL, Howes DS, et al: Efficacy of a "standard" seizure workup in the emergency department. Ann Emerg Med 1986;15:33-39. [B] 25. Ettinger AB: Structural causes of epilepsy. Tumors, cysts, stroke, and vascular malformations. Neurol Clin 1994;12:41-56. [C] 26. Fagan KJ, Lee SI: Prolonged confusion following convulsions due to generalized nonconvulsive status epilepti- cue. Neurology 1990;40:1689-1694. [C] 27. Finelli PF, Cardi JK: Seizure as a cause of fracture. Neurology 1989;39:858-860. [B] 28. Fisher RS (ed): Imitators of Epilepsy. New York, Demos Publications, 1994. [C] 29. Freedland ES, McMicken DB: Alcohol related seizures, I: Clinical presentation and management, d Emerg Med 1993;11:463-473. [C]

MAY 1997 2£:5 ANNALS OF EMERGENCY MEDICINE 7 1 7


30. Freedland ES, McMicken DB: Alcohol related seizures, II: Clinical presentation and management. J Emerg Med 1993;11:605-618. [C] 31. French J: The long-term therapeutic management of epilepsy. Ann Intern Med 1994; 120:411. [C] 32. Gates JR, Ramani V, Whalen S, et al: Ictal characteristics of pseudoseizures. Arch NeuroI 1985;42:1183-1187. [131 33. Graber TW, Yee AS, Baker FJ: Magnesium physiology, clinical disorders, and therapy Ann Emerg Med 1981;10:49-57. [C] 34. Green SM, Rothrock SG, Clem KJ, et al: Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics 1993;92:527-534. [13] 35. Gumnit RJ, Gates JR: Psychogenic seizures. Epilepsia 1986;27(suppl 2):$124-$129. [C] 36. Hauser WA, Rich SS, Annegers JF, et al: Seizure recurrence after a 1st unprovoked seizure: An extended follow- up. Neurology 1990;40:1163-1170. [13] 37. Hauser WA: The natural history of drug resistant epilepsy: Epidemiologic considerations. Epilepsy Res 5uppl 1992;5P:25-28. [C] 38. Hauser WA, Annegers JF, Kurland LT: Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia 1993;34:453-468. [13] 39. Henneman PL, DeRoos E Lewis RJ: Determining the need for admissions in patients with new-onset seizures. Ann Emerg Med 1994; 24:1108-1114. [13] 40. Herman LL, Stoshak, Rittenberry TJ: Long QT syndrome presenting as a seizure. Amd Emerg Med 1992;10:435-438. [C] 41. Hoefnagels WA, Padberg GW, OverwegJ, et al: Syncope or seizure? The diagnostic value of the EEG and hyperventilation test in transient loss of consciousness, d Neurosurg Psychiatry 1991;54:953-956. [B] 42. Holtzman DM, Kaku DA, So YT: New-onset seizures associated with human immunodeficiency virus infection: Causation and clinical features in 100 cases. Amd Med 1989;87:173-177. [B] 43. Hopkins A, Garman A, Clarke C: The first seizure in adult life: Value of clinical features, electroencephalogra- phy, and computerized tomographic scanning in predic- tion of seizure recurrence. Lancet 1988; 1:721-726. [B] 44. Huang SK, Ezri MD, Hauser RG, et al: Carotid sinus hypersensitivity in patients with unexplained syncope: Clinical, electrophysiologic, and long-term follow-up observations. Am Heartd 1988; 116:989-996. [13] 45. Jagoda A, Riggo S: Emergency department approach to managing seizures in pregnancy Ann Emerg Meal 1991;20:80-85. [C]

46. Jagoda A, Riggio S: Pyschogenic convulsive seizures. AmJ Emerg Med 1993;11:626-631. [C] 47. Kirby S, Sadler RM: Injury and death as a result of seizures. Epilepsia 1995;36:25-28. [B] 48. Knight A, R_hind E: Epilepsy and pregnancy: A study of 153 pregnancies in 59 patients. Epilepsfa 1975;16:99- 110. [B] 49. Kothari SS: When epilepsy masquerades as heart disease. Awareness is key to avoiding misdiagnosis. Postgrad Med 1990;88:167-171. [C] 50. Krumholz A, Fishers RS, Lesser RE et al: Driving and epilepsy: A review and reappraisal. JAMA 1991;265:622- 626. [C] 51. Leis AA, Ross MA, Summers AK: Psychogenic seizures: Ictal characteristics and diagnosing pitfalls. Neurology 1992;42:95-99. [C] 52. Leppik It, Wolff DL: Antiepileptic medication interactions. Neurol Clin 1993;11:905-921. [C] 53. Libman MD, Potvin L, Coupal L, et al: Seizure vs syncope: Measuring serum creatinine kinase in the emergency department. J Gen Intern Med 1991; 6:408- 412. [B] 54. Linzer M: Cardiovascular causes of LOC in patients with presumed epilepsy: A cause of the increased sudden death rate in people with epilepsy? Amy Med 1994;96:146. [C] 55. Luhdorf K, Jensen LK, Plesner AM: Etiology of seizures in the elderly Epilepsia 1986;27:458-463. [B] 56. Mattson RH: Current challenges in the treatment of epilepsy. Neurology 1994;44(suppl 5):$4-$9. [C] 57. McCullen GM, Brown CC: Seizure-induced thoracic burst fractures. A case report. Spine 1994;19:77-79. [C] 58. Messing RO, Simon RP: Seizures as a manifestation of systemic disease. Neurol Clin 1986;4:563-584. [C] 59. Moss AJ, Schwartz pJ, Crampton RS, et ah The long QT syndrome: Prospective longitudinal study of 328 fam- ilies. Circulation 1991 ;84:1136-1144. [B] 60. Myers JA, Earnest MP: Generalized seizures and cocaine abuse. Neurology 1984;34:675-676. [C] 61. Neugebauer R, Paik M, Hauser WA, et al: Stressful life events and seizure frequency in patients with epilepsy. Epilepsia 1994;35:336-343. [B] 62. Ng SK, Hauser WA, Brust JCM, et al: Alcohol consumption and withdrawal in new-onset seizures. N Engld Med 1988;319:666-673. [B] 63. Ng SK, Hauser WA, Brust JC, et al: Hypertension and the risk of new-onset unprovoked seizures. Neurology 1993;43:425-428. [B] 64. Olson K: Seizures associated with poisoning and drug overdose. Am J Emerg Med 1993;11:565. [B]

7 1 8 ANNALS OF EMER6ENCY MEDICINE 29:5 MAY 1997

A C E P C L I N I C A L P O L I C Y

65. Orringer C, Eustace J, Christian D, et al: Natural history of lactic acidosis after grand mal seizures. N Engl J Med 1977;297:796-799. [B] 66. Osbom H: Single dose oral phenytoin loading. Ann Emerg Med 1987;16:407. [B] 67. Pacia SV, Devinsky O, Luciano DJ, et al: The prolonged QT syndrome presenting as epilepsy: A report of two cases and literature review. Neurology 1994;44:1408-].410. [C] 58. Pear BL: Bilateral fracture dislocation of the shoulder

- - an uncommon complication of a convulsive seizure. N Engld Med 1976; 283:135-136. [C] 59. Pellock JM: Standard approach to antiepileptic drug treatment in the United States. Epilepsia 1994;35:$11- S18. [C] 70. Powers RD: Serum chemistry abnormalities in adult patients with seizures. Ann Emerg Med 1985;14:416-420. tel 71. Ramirez-Lassepas M, Cipolle RJ, Morillo LR, et al: Value of computed tomographic scan in the evaluation of adult patients after their first seizure. Ann NeuroI 1984;15:536-543. [B] 72. Raskin NH, Fishman RA: Neurologic disorders in renal failure. N EnglJ Med 1976;294:143-148,204-210. tel 73. Reinus WR, Wippold FJ, Erikson KK: Seizure patient selection for emergency computed tomography. Ann Emerg Med 1993;22:1298-1303. [B] 74. Ritaccio AL: Reflex seizures. Neurol Clin 1994;12:57- 83. tel 75. Rosenthal RH, Helm ML, Waeckerle JE et al: First time major motor seizures in an emergency department. Ann Emerg Med 1980;9:242-245. [B] 76. Sanchetee PC, Venkataraman CS, Dhamija RM, et al: Epilepsy as a manifestation of neurocysticercosis. J Assoc Physicians India 1991;39:325-328. [B] 77. Scheuer ML, Pedley TA: The evaluation and treatment of seizures. N DGI d Med 1990;323:1468-1474. [C] 78. Schmidt D: The effect of pregnancy on the natural history of epilepsy, in Janz D, Dam M, Richens A, et al (eds): Epilepsy, Pregnancy and the Child. New York, Raven Press, 1982:3-1,}. [C] 79. Sempere AE Villaverd FJ, Martinez-Menedez B, et al: First seizure in adults: Prospective study from the emergency department. Acta Neural Scand 1992;86:134-138. [B] 80. Talan D, Hoffman J, Yoshikawa T, et al: Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: State of the art. Rev Infect Dis 1988;10:365-375. [C]

81. Tardy B, Lafond P, Convers P, et al: Adult first generalized seizure: Etiology, biological tests, KEG, CT scan, in an ED. AmJEmerg Med 1995;13:1-5. [B] 82. Temkin NR, Dikmen SS, Wilensky AJ, et al: A randomized, double-blind study of phenytoin for the pre- vention of post-traumatic seizures. N Engl J Med 1990;323:497-502. [A] 83. The Medical Letter Inc: Drugs for epilepsy. The Medical Letter on Drugs and Therapeutics 1995;37:37-40. tel 84. Turnbull TL, Vanden Hoek TL, Howes DS, et al: Utility of laboratory studies in the emergency department patient with a new-onset seizure. Ann Emerg Med 1990;19:373-377. [B] 85. Venna N, Sabin TD: Tonic focal seizures in nonketotic hyperglycemia of diabetes mellitus. Arch Neurol 1981;38:512-514. [C] 86. Volow MR: Pseudoseizures: An overview. South Medy 1986;79:600-607. [C] 87. Willmore LJ: Post-traumatic seizures. Neurol Clin 1993;11:823-831. [C] 88. Wong MC, Suite ND, Labar DR: Seizures in human immunodeficiency virus infection. Arch Neurol 1990;47:640-642. [B] 89. Wyllie E, Lueders H, Pippenger C, et al: Posdctal serum creatinine kinase in the diagnosis of seizure disorders. Arch NeuroI 1985; 42:123-126. [B] 90. Yerby MS: Epilepsy and pregnancy. New issues for an old disorder. Neurol Clin 1993; 11:777-786. [C]

MAY 1997 29:5 ANNALS OF EMERGENCY MEDICINE 7 t 9


Quality Assurance Form: Seizure Clinical Policy INSTRUCTIONS: Use this form to review medical records of patients who are 6 years or older who have had a seizure and are not in status epilepticus.

D o c u m e n t a t i o n R e v i e w

Does the medical record contain a description of the following:

1. Seizure history

2. Medications

3. Medical history

Yes No

Is there documentation that the physical examination included the following:

4. Vital signs: blood pressure, pulse, respirations, temperature

5. Neurologic examination

6. Mental status

Yes No

C o m m e n t s

7 2 0 ANNALS 0I EMERGENCY MEDICINE 29:5 MAY 1997


Quality Assurance Form: Seizure Clinical Policy-continued

Instructions: Draw horizontal lines across EtA Form for each positive finding. Draw vertical lines down QA Form for each action taken. Ceuntthe dots that are intersected by both horizontal and vertical lines {A: ). Then cou bisected by a horizontal line ( B : ) . Divide A the QA ratio for this medical record.

Ratio = Rules Followed (A) Rules Called for by Findings,

Actions: If done, draw a vertical line down the form

Findings: if positive, draw a horizontal line

History

Seizure history Epileptic with new seizure type or pattern, or no p~ No previous seizure?

Medications Patient taking oral hypogfycemics/insulin?

Physical Examinati

Neurologic examination Mental status not at baseline but improving? Mental status not at baseline and not improving?

New focal abnormality?

Assessment

First seizure without known etiology or previously dia! in pattern without attributable cause- With mental status returning to baseline?

MAY 1997 29:5 ANNALS OF EMERGENCY MEDICINE 72 1


Quality Assurance Form: Seizure Clinical Policy-continued

Actions: If done, draw a vertical line down the form

Findings: If positive, draw a horizontal line across the form

Assessment-Continued

First seizure without known etiology or previously diagnosed seizure with change in pattern without attributable cause- With mental status not returning to baseline?

Previously diagnosed epilepsy? Alcohol-related seizure that is not a first seizure? Drug/toxin related seizure that is not a first seizure?

Admission? Transfer? Discharge?

Disposition

+ ~ o + o +

D ~ ® N N N N N NNNNNNN N N N E~ f fao~ ~ II

Totals

Total dots with intersecting horizontal & vertical lines:

Total dots with horizontal lines:

QA Ratio =


ACEP CL IN ICAL POLICY

Quick Reference Form: Seizure Clinical Policy For patients 6 years or older who have had a seizure, and are not in status apilepticus.

This clinical policy is no t i n t ended for use with patients in whom seizure is due to eclampsia or to acute head trauma.

Circle line number if yes. Bolded actions are rules. Actions not bolded are guidelines.

Chief complaint Patient 6 years or elder who has had a seizure, and is not in status epilepticus.

History 1. Seizure history-known epileptic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . seek exacerbants, antiepileptic drug levels 2. Seizure history-epileptic with new seizure type or pattern, or no previous workup . . . . . . . . . . . seek etiolegy/exacerbants, evaluate as first seizure, antiepileptic

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . drug levels 3. Seizure history-no previous seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . evaluate as first seizure 4. Circumstances-potential deceleration injury secondary to seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-spine immobilization, C-spine x-ray 5. Exacerbants-drug/toxins/occupational exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . toxicologic screen/levels 6. Exacerbants-ethanol use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . glucose determination Medications 7. Patient taking antiepileptic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . antiepileptic drug levels 8. Patient taking oral hypoglycemics/insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . glucose determination, administer dextrose 9. Patient taking anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . coagulation studies, noncontrast head CT Medical History 10. Recent head trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . noncontrast head CT

11. Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . glucose determination 12. Heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cardiac monitor, ECG 13. Coagulopathy/platelet disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CBC, coagulation studies, noncontrast head CT, treat coagulopathy 14. History of electrolyte abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . electrolytes

15. History of renal failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . electrolytes, BUN/creatinine 16. No recent menses in patient with reproductive potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pregnancy test

17.2nd half of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . assess blood pressure, deep tendon reflexes, and urine protein, assess fetal statue, consult obstetrician 18. HIV positive/immunesuppressien . . . . . . . . . . . . . . . . . . . . . . . . . . . . CBC, MRI or CT (with and without contrast), LP if not contraindicated by neuroimaging studies 19. Alcoholism . . . . . . . . . . . electrolytes/magnesium level, BUN/creatinine, glucose determination, toxicologic screen, alcohol level, CBC, platelets, prothrombin time,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . noncontrast head CT, thiamine administration, magnesium administration

Physical Examination 20. Vital signs-temperature elevation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . drug screen, LP, antibiotics, manage temperature 21. Vital signs-abnormal respirations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . supplemental oxygen, ABG/pulse oximetry 22. Vital signs-bradycardia/tachycardia/irregular pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cardiac monitor, ECG

23. Head-signs of recent trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . noncontrast head CT 24. Neck-cervical spine tenderness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-spine immobilization, C-spine x-ray

25. Neck-stiff neck on flexion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . blood culture, noncontrast head CT, LP, antibiotics 26. Neurologic examination-mental status not at baseline but improving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ebserve, reexamine, IV access

27. Neurologic examination-mental status not at baseline and not improving . . . IV access, oxygen/pulse oximetry, electrolytes, glucose level, rapid glucose . . . . . . . . . . . . . determination/administer dextrose, noncontrast head CT, observe, reexamine, rectal temperature, cardiac monitor, ABC/carboxyhemoglobin, . . . . . . . . calcium hwel,magnesium level, BUN/creatinine, toxicologic screen/levels, alcohol level, CBC, UA, EEG, ECG, LP, opiate antagonist, thiamine administration,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . magnesium administration, consult/admit 28. New focal abnormality . . . . . . . IV access, noncontrast head CT, observe, reexamine, consult/admit, supplemental oxygen, oximetry, electrolytes, calcium,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BUN/creatinine, toxicologic screen, CBC, LP

Assessment 29. First seizure without known etiology or previously diagnosed seizure with change in pattern without attributable cause-With mental status returning to baseline . . . . . . . . . . . evalaate for pregnancy, serum sodium level, glucose determination, noncontrast head CT or schedule neuroimaging, provide referral for . . . . . . follow-up care or admit, oxygen/pulse oximetry, cardiac monitor, electrolytes, calcium level, BUN/creatinine, toxicologic screen, CBC, RPR, HIV testing, UA,

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EEG, LP, antiepileptic drug, glucose, consult

MAY 1987 29:5 ANNALS OF EMERGENCY MEDICINE 7 2 3

ACEP CL IN ICAL POLICY

Quick Reference Form: Seizure Clinical Policy-continued Assessment- continued 30. First seizure without known etiology or previously diagnosed seizure with change in pattern without attributable cause-With mental status not returning to baseline . . . . . . . reexamine, IV access, oxygen/pulse oximetry/ABG, evaluate for pregnancy, electrolytes, glucose determination/administer dextrose,

. . . . . . . . . . noncontrast head CT, observe/admit, rectal temperature, cardiac monitor, AB6/carboxyhemoglobin, calcium level, magnesium level, BUN/creatinine, . . . . . . . . . . . . . toxicologic screen/levels, alcohol level, CBC, UA, EEG, ECG, LP, opiate antagonist, thiamine administration, magnesium administration, consult/admit

31. Previously diagnosed epilepsy . . . . observe, manage antiepileptic drug levels, provide referral for follow-up care, evaluate compliance, evaluate for drug . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . interaction, discuss any change in dosing with primary care physician

32. Alcohol-related seizure (that is not a first seizure) . . . . . . observe, provide referral for follow-up care for seizure, electrolytes, magnesium level, rapid blood . . . . . . . . . . . . glucose determination or administer dextrose, CBC, thiamine administration, magnesium administration, treat ethanol withdrawal, refer for drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . rehabilitation

33. Drug/toxin related seizure (that is not a first seizure) . . . . . . . . observe, provide referral for follow-up care, decontamination, specific antidotes/management, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . treat for drug toxicity/withdrawal, refer for drug abuse rehabilitation

Disposition 34. Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . transfer care to accepting physician 35. Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . follow ACEP and other applicable transfer policies 36. Discharge . . . . . . . . . . . . . . . . . provide referral for follow-up care, provide instructions regarding treatment and circumstances that require return to

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . emergency department

Abbreviations

ABG=arterial blood gas BUN=blood urea nitrogen CBC=complete blood count C-spine=cervical spine CT=computed tomography EOG=electrocardiegram EEG=electroencephalogram

HIV=human immunodeficiency virus IV=intravenous LP=lumbar puncture MRl=magnetic resonance imaging RPR=rapid plasma reagin UA=urinalysis

Notes:


clinical policy for the initial approach to patients

Documents