The evaluation and treatment of a patient with seizures in the emergency department (ED) can vary dramatically, depending on whether the patient has a history of epilepsy or is presenting with his or her first seizure. It is also a place in which experience with and knowledge of chronic epilepsy care and antiepileptic drugs (AEDs) can be greatly beneficial.

Care of patients with known epilepsy may be too aggressive in many cases. For instance, if an individual with poorly controlled epilepsy arrives by ambulance after a habitual seizure and has recovered to his or her normal interictal state of health, aggressive evaluation (e.g., lumbar puncture) or treatment (e.g., phenytoin load) are probably unnecessary.

On the other hand, it is inadvisable to casually attribute abnormal findings such as fever, focal weakness, or altered awareness to the postictal state. These findings may signal new or deteriorating disorders. Individuals with epilepsy are still subject to the same medical problems as unaffected individuals.

Use of the EEG

Resist the temptation to use the EEG (or other tests) as a substitute for clinical acumen. An urgent 24-hour-per-day EEG service should only be used selectively. In many cases, it is appropriate to provide treatment based on the clinical impression at odd hours and wait until morning to obtain a standard EEG.

Nevertheless, having an EEG technologist available at all times can be very important in evaluating some patients in the ED. Important indications for urgent EEG studies are:

• to distinguish successful resolution of convulsive status epilepticus from a conversion to “subtle” status epilepticus
• to rule out seizures as a cause of unusual behavior or movements
• to identify individuals with nonconvulsive status epilepticus If muscle and movement artifacts present difficulty in interpreting these events, video-EEG can be extremely useful

Use of neuroimaging

Many patients with epilepsy do not require neuroimaging in the ED. These are seizure patients with typical febrile or recurrent seizures related to previously treated epilepsy who recover completely from their seizure. Often, these patients are brought to the ED when they have a seizure while alone in a public place. They can report that their seizure was typical.

Neuroimaging is a useful tool in evaluating some patients with seizures, however. Any change in the patient’s seizure pattern or type warrants an emergent scan, as do prolonged postictal confusion or worsening mental status. An emergent neuroimage should be taken in patients who have epilepsy with recurrent seizures whenever the physician suspects a serious structural lesion.26,27

There is evidence26 supporting a higher frequency of life-threatening lesions in patients with:

• new focal deficits
• persistent altered mental status (with or without intoxication)
• fever
• recent trauma
• persistent headache
• history of cancer
• history of anticoagulation
• suspicion of acquired immunodeficiency syndrome (AIDS)

A patient who has completely recovered from his or her seizure and for whom no clear-cut exacerbating factor has been identified should be scheduled for a scan as part of the disposition from the ED. After obtaining a scan to ensure the absence of a new or developing structural lesion, the physician in the ED may ask the patient to follow up with the primary physician.

If an MRI scan is performed, a seizure protocol should be used. This includes thin coronal cuts through the amygdala, hippocampus, and mesial temporal regions, using T1, T2, and FLAIR pulse sequences.

Neck immobilization

Spinal immobilization in individuals after seizures is rarely necessary. In one retrospective study, 1,656 cases over a 10-year period were reviewed, and no spinal injuries were found.25

Communication

Contacting the patient’s treating physician is vital to good quality and continuity of care. In one study, AED therapy was altered by the ED in nearly 20% of epilepsy patients who were evaluated and discharged from an ED, but documentation that these changes were discussed or communicated to the primary treating physician was lacking in 85% of these patients.5 Also, ask the patient to contact the physician who manages his or her seizures.

Driving

Review issues of compliance with the patient, and inform him or her about the state laws that pertain to driving. In states where the physician is required by law to inform the Department of Motor Vehicles of acute seizures (e.g., California, Delaware, New Jersey, Pennsylvania), this should be done by form from the ED.

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535.
With permission from Elsevier (www.elsevier.com).
Reviewed and revised May 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.

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