What the ACEP Seizure Clinical Policy Doesnt Tell Us about Adult Seizure and Status Epilepticus Pati

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What the ACEP Seizure Clinical Policy Doesnt
Tell Us about Adult Seizure and Status
Epilepticus PatientsA view from the real
clinical world.
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J. Stephen Huff, MD
Associate ProfessorEmergency Medicine and
NeurologyDepartment of Emergency
MedicineUniversity of Virginia Health
SystemCharlottesville, Virginia, United States
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Objectives

• Review Clinical Policy on Seizures
• Discuss policy development
• Show limitations of policy development
• Demonstrate practical use of policy

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Process

• Present brief case
• Review ACEP Clinical Policy
• Show policy application and limitations

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Ann Emerg Med 200443605

• Clinical policy Critical issues in the
  evaluation and management of adult patients
  presenting to the emergency department with
  seizures
• Not a comprehensive manual
• No substitute for clinicians judgment

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A word about policy development

• Key questions from membership
• Subcommittee formation
• Literature search
• Review and grade literature
• Strength of evidence recommendations
• Peer and expert review

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Level of Recommendations

• Level A recommendations
• High degree of clinical certainty
• Strength of evidence Class I or multiple II
• Level B recommendations
• Reflect moderate clinical certainty
• Class II studies or other
• Level C recommendations
• Preliminary or inconclusive evidence
• Panel consensus

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Clinical History 1

• A 21 year-old college student presents to the ED
  after a witnessed generalized first seizure at a
  party. His examination is normal at this time.
  Past medical history is unremarkable. His history
  and that of his roommates indicate that there was
  nothing unusual about the evening. Are additional
  tests necessary?

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New-Onset Seizure Lab

• What laboratory tests are indicated in the
  otherwise healthy adult patient with a new-onset
  seizure who has returned to baseline normal
  neurologic status?

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New-Onset Seizure Lab

• Level A recommendations - None

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New-Onset Seizure Lab

• Level B recommendations
• 1. Determine a serum glucose and sodium level on
  patients with first-time seizure with no
  comorbidities who have returned to their
  baseline.
• 2. Obtain a pregnancy test if a woman is of
  child-bearing age.
• 3. Perform a lumbar puncture, after a head
  computed tomography (CT) scan, either in the ED
  or after admission, on patients who are
  immunocompromised.

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New-Onset Seizure Lab

• The policy suggests that a serum glucose and
  sodium determinations are appropriate in this
  patient. Would you do anything differently with
  regard to laboratory testing?

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Case 1 - Conclusion

• The patient and friends had been experimenting
  with cocaine
• Toxicologic analysis confirmed the presence of
  cocaine metabolites
• The cocaine is the likely precipitant of his
  seizure. This patient should not be given a
  diagnosis of idiopathic epilepsy nor does he need
  anti-epileptic medications administered.

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New-Onset Seizure Lab

• Commentary- Evidence-based recommendations
  suggest that laboratory work is of limited
  utility
• In practice routine testing is prevalent
• An approach directed by history and physical will
  have higher yield than an undirected approach

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Clinical History 2

• A 30 year-old graduate student comes to the ED
  with a friend following a generalized convulsion.
  He is healthy and takes no medications. He had
  been evaluated and released from the ED after a
  bicycle accident one week before and had attended
  classes this week in spite of an unusual
  headache. His examination is normal at this time.
  Past medical history is unremarkable. Should
  imaging be done in the ED?

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New-Onset Seizure CT

• Which new-onset seizure patients who have
  returned to a normal baseline require a head CT
  scan in the ED?

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New-Onset Seizure CT

• Level A recommendations - None

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New-Onset Seizure CT

• Level B recommendations
• When feasible, perform neuroimaging of the brain
  in the ED on patients with a first-time seizure.
• Deferred outpatient neuroimaging may be used when
  reliable follow-up is available.

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New-Onset Seizure CT

• The policy suggests that imaging may be deferred
  in this patient. Would you do anything different?

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Picture
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Case 2

• Imaging showed a large frontal epidural hematoma
  without midline shift. This illustrates the
  insensitivity at times of the bedside neurologic
  examination. The history of recent trauma should
  trigger the decision to pursue neuroimaging.

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New-Onset Seizure CT

• Commentary-the history of trauma was the driving
  force in this case
• In US practice, if logistically possible,
  patients will likely be imaged in the ED
• The policy attempts to allow the clinician
  options if there is difficulty in getting prompt
  CT, or if elective MRI imaging might be promptly
  obtained
• As technology evolves policy will change

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Clinical History 3

• A visiting clerical worker has a seizure while
  doing an audit at a local business. He is awake,
  alert, and examination is normal. There is no
  seizure history or significant medical history.
  He blames the event on late hours and poor
  sleeping quarters. Laboratory evaluation and
  initial imaging are performed and are
  unremarkable.
• What would you do?

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New-Onset Seizure Admission

• Which new-onset seizure patients who have
  returned to normal baseline need to be admitted
  to the hospital and/or started on an
  antiepileptic drug?

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New-Onset Seizure Admission

• Level A recommendations - None
• Level B recommendations - None

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New-Onset Seizure Admission

• Level C recommendations
• Patients with a normal neurologic examination can
  be discharged from the ED with outpatient
  follow-up.
• Patients with a normal neurologic examination, no
  comorbidities, and no known structural brain
  disease do not need to be started on an
  antiepileptic drug in the ED.

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New-Onset Seizure Admission

• The policy suggests that this patient may be
  discharged for outpatient follow-up without
  starting on medications
• Do you agree?

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New-Onset Seizure Admission

• Level C recommendations
• Patients with a normal neurologic examination can
  be discharged from the ED with outpatient
  follow-up.
• Patients with a normal neurologic examination, no
  comorbidities, and no known structural brain
  disease do not need to be started on an
  antiepileptic drug in the ED.

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Case 3

• The early seizure recurrence risk is simply not
  known. If discharged, the patient must have a
  stable social situation. Staying alone in a hotel
  room is not sufficient.
• Perhaps the best option is to admit the patient
  for observation and an expedited diagnostic
  work-up

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New-Onset Seizure Admission

• Commentary-Policy attempts to recognize the
  varied approach to this patient type
• new-onset seizures do not need to be admitted-
  with reservations
• normal exam
• structurally normal brain
• safety

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Case 4

• A patient with a known seizure disorder for many
  years and a history of good seizure control
  presents to the ED after a seizure. He admits
  that he has missed his only medication,
  phenytoin, for several days. A phenytoin level is
  very low.

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Effective Dosing Phenytoin

• What are effective phenytoin or fosphenytoin
  dosing strategies for preventing seizure
  recurrence in patients who present to the ED
  after having had a seizure with a subtherapeutic
  serum phenytoin level?

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Effective Dosing Phenytoin

• Level A recommendations
• None specified
• Level B recommendations
• None specified

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Effective Dosing Phenytoin

• Level C recommendations
• Administer an intravenous or oral loading dose of
  phenytoin or intravenous or intramuscular
  fosphenytoin, and restart daily oral maintenance
  dosing.

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Case 4

• What would you do?
• IV phenytoin or fosphenytoin?
• PO phenytoin loading strategy? How?
• Resume medications?

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Case 4

• The patient is given an oral loading of phenytoin
  at 18 mg/kg and started back on his seizure
  medication. He has some nausea following the
  medication

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Effective Dosing Phenytoin

• Commentary- No data exist to rationally guide
  therapy
• The risk of early seizure recurrence in this
  patient population is not known

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Case 5

• A patient with a history of difficult-to-control
  seizures presents to the emergency department
  minimally responsive after a flurry of seizures.
  There have been at least three witnessed seizures
  while in route. Current medications include
  valporate and levetiracetam.

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Case 5

• Airway control is thought to be adequate when
  supplemented with a nasopharyngeal airway
• Lorazepam 4 mg is administered intravenously
• Phenytoin loading is accomplished

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Status Epilepticus Refractory

• What agent(s) should be administered to a patient
  in status epilepticus who continues to seize
  after having received a benzodiazepine and a
  phenytoin?

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Status Epilepticus Refractory

• Level A recommendations
• None specified
• Level B recommendations
• None specified

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Status Epilepticus Refractory

• Level C recommendations
• Administer 1 of the following agents
  intravenously
• high-dose phenytoin
• phenobarbital
• valproic acid
• midazolam infusion
• pentobarbital infusion
• propofol infusion.

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Case 5

• The clinical policy intimates that many options
  are equally effective (or
  ineffective).
• What would you do in this case?
• What would you do?
• Which drug?
• How much?

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Case 5

• Many opinions
• No data exist to guide specific therapies
• Reasonable to empirically administer valproate in
  this patient, particularly if levels are
  demonstrated to be low

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Status Epilepticus Refractory

• Commentary- Many options possible without clear
  superiority of one regimen
• Midazolam infusion
• Propofol infusion

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Case 6

• A patient with a known seizure disorder and
  static encephalopathy (cerebral palsy) has a
  seizure
• Normally walks with assistive devices but is
  high-functioning intellectually
• Lives with family and takes two medications for
  seizures, valproate and carbamazepine

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Case 6

• He receives lorazepam 4 mg IV in route to the
  hospital
• No further generalized convulsive activity is
  observed
• Occasional twitching of the eyelids with jerking
  of the eyes to the left
• Not awakening after 30 minutes

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EEG in ED

• When should EEG testing be performed in the ED?

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EEG in ED

• Level A recommendations
• None specified
• Level B recommendations
• None specified

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EEG in ED

• Level C recommendations
• Consider an emergent EEG in patients suspected of
  being in nonconvulsive status epilepticus or in
  subtle convulsive status epilepticus, patients
  who have received a long-acting paralytic, or
  patients who are in drug-induced coma.

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Case 6

• The clinical policy intimates that an emergency
  EEG should be considered
• What would you do in this case?

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Case 6

• Though access to EEG varies widely, it is prudent
  to consult a neurologist or transfer such a
  patient for consideration of EEG
• Status epilepticus was present on EEG
• Additional medication was added

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Case 6

• The natural history of subtle status
  epilepticus, or non-convulsive status epilepticus
  is still being delineated, but there is consensus
  that the excessive electrical activity alone is
  injurious to the brain

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EEG in ED

• Commentary-Access to EEG varies widely but it is
  prudent to consult a neurologist or transfer such
  a patient for consideration of EEG
• This is an evolving clinical area without strong
  published evidence to guide recommendations.

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Key Learning Points

• Reviewed ACEP Clinical Policy
• Showed interactions with clinical world.

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Questions??

• www.ferne.orgferne_at_ferne.orgJ. Stephen Huff,
  MDjshuff_at_virginia.edu

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