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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EUp to 5% of individuals in the United States will experience a nonfebrile seizure during their lifetime. Yet, the accurate diagnosis of seizure can be challenging for emergency department (ED) physicians. This article discusses the American College of Emergency Physicians\u0027 2014 update regarding the evaluation and management of adult patients presenting to the ED with seizures.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENeuroimaging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEmergency Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EUp to 5% of individuals in the United States will experience a nonfebrile seizure during their lifetime. Yet, the accurate diagnosis of seizure can be challenging for emergency department (ED) physicians. Jordan Bonomo, MD, University of Cincinnati Medical Center, Cincinnati, Ohio, USA, discussed the American College of Emergency Physicians\u0027 (ACEP) 2014 update regarding the evaluation and management of adult patients presenting to the ED with seizures [Huff JS et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EIn this update of the 2004 clinical policy, seizure definitions were modified. For example, status epilepticus (SE) was defined as clinical or electroencephalographic (EEG) seizure activity for \u0026gt; 5 minutes, continuously or recurrently, without full recovery between events. SE is categorized as convulsive, nonconvulsive, or refractory. Dr Bonomo pointed out that most seizures do not meet these criteria because seizure activity lasts \u0026lt; 5 minutes.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe 2014 policy provides level B recommendations that all patients presenting with seizure should be evaluated with blood glucose and sodium levels. In addition, all women should be tested for pregnancy, and immunocompromised patients should undergo lumbar puncture. Although the policy does not provide level A recommendations regarding the use of computed tomography (CT) imaging, cranial CT imaging should be performed on all patients who present with their first-ever seizure. In addition, neurologic experts recommend that magnetic resonance imaging (MRI) should be conducted on first seizure presentation, because up to 15% of patients with a normal CT will demonstrate a suspect lesion on MRI.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EBecause up to 15% of patients with acute ischemic stroke (AIS) will present with seizure at the onset of the AIS, it is important to determine if a witnessed seizure is an AIS mimic. The only protocol that can accurately screen for AIS is MRI with diffusion-weighted imaging (DWI). In one study, DWI-only MRI was rapid, and the odds ratio of positive DWI findings in patients with \u0026gt; 1 symptoms was 9.4 (95% CI, 3.8 to 23.5) [Eichel R et al. \u003Cem\u003EJ Neurol Sci.\u003C\/em\u003E 2013]. There were no false positives related to seizure reported. The purpose of MRI imaging in patients presenting with seizure is to identify the underlying source of the seizure, such as a malignancy, vascular pathology, or structural issues.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EWhen a patient presents with seizure, it is important that pharmacologic control is achieved [Huff JS et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2014]. The speed of termination is important because development of SE is associated with poorer prognosis. Patients presenting with seizure are admitted to the hospital depending on their risk of seizure recurrence, and the morbidity and mortality associated with recurrence. Patients should be discharged from the ED only if they have a normal (or baseline) neurologic exam.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EInitiation of antiepileptic drug (AED) treatment in the ED does not affect long-term outcomes in patients presenting with their first seizure; therefore, the 2014 ACEP policy does not recommend that patients with first-time seizure receive an AED in the ED (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15527\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15527\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15527\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ERecommendations for Initiating AED\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003EIn patients who present with seizure in the context of subtherapeutic AED levels, a loading dose should be administered. To determine the loading dose, the current corrected serum level should be subtracted from the goal serum level and multiplied by the dosing weight in kilograms. A loading dose of phenytoin can be administered either intravenously (IV) or orally; however, IV phenytoin can be loaded faster so that the patient can be discharged from the ED quicker [Swadron SP et al. \u003Cem\u003EAcad Emerg Med.\u003C\/em\u003E 2004].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EA patient presenting with SE who continues to experience seizures after receiving benzodiazepine, IV phenytoin, fosphenytoin, or valproate may be administered (level B recommendation), or IV levetiracetam, propofol, or barbiturates may be administered (level C recommendation) [Huff JS et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2014]. In such cases, systolic blood pressure and mean arterial pressure should be maintained at \u0026gt; 90 and \u0026gt; 70, respectively. In addition, the Neurocritical Care Society\u0027s (NCS) guidelines for the evaluation and management of SE recommend that these patients quickly receive continuous infusion of midazolam or propofol [Brophy GM et al. \u003Cem\u003ENeurocrit Care\u003C\/em\u003E. 2012].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EIn all patients who are suspected to have nonconvulsive SE, as well as any patient who underwent hypothermia therapy after cardiac arrest, continuous EEG (cEEG) should be performed [Huff JS et al. \u003Cem\u003EAnn Emerg Med.\u003C\/em\u003E 2014]. In one study, up to 33% of patients who received hypothermic therapy for cardiac arrest experienced seizures, which was associated with a greater rate of mortality [Knight WA et al. \u003Cem\u003EEpilepsy Res.\u003C\/em\u003E 2013]. However, it is unknown whether seizure control decreases mortality in these patients. In patients with suspected nonconvulsive SE, the NCS guidelines recommend that cEEG should be initiated within 1 hour of event onset and continued for at least 48 hours [Brophy GM et al. \u003Cem\u003ENeurocrit Care\u003C\/em\u003E. 2012].\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EIn conclusion, Dr Bonomo highlighted that all patients presenting with a first-ever seizure should undergo CT, and potentially MRI, imaging, whereas patients with suspected nonconvulsive SE should be monitored by cEEG. In addition, he pointed out that an appropriate loading dose of phenytoin in patients with subtherapeutic levels is dependent on albumin. Treatment of refractory seizures should be quickly escalated, and propofol may be needed.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/46\/16.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzohg1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzohg1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}