1. J. Stephen Huff, MD 1 What the ACEP Seizure Clinical Policy Doesn’t Tell Us about Adult Seizure and Status Epilepticus Patients… What the ACEP Seizure Clinical Policy Doesn’t Tell Us about Adult Seizure and Status Epilepticus Patients… A view from the real clinical world….

2. J. Stephen Huff, MD 2 Associate Professor Emergency Medicine and Neurology Department of Emergency Medicine University of Virginia Health System Charlottesville, Virginia, United States

3. J. Stephen Huff, MD 3 Objectives Review Clinical Policy on Seizures… Discuss policy development Show limitations of policy development Demonstrate practical use of policy

4. J. Stephen Huff, MD 4 Process Present brief case Review ACEP Clinical Policy Show policy application and limitations

5. J. Stephen Huff, MD 5 Ann Emerg Med 2004;43:605 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 clinician’s judgment

6. J. Stephen Huff, MD 6 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

7. J. Stephen Huff, MD 7 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

8. J. Stephen Huff, MD 8 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?

9. J. Stephen Huff, MD 9 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?

10. J. Stephen Huff, MD 10 Level A recommendations - None New-Onset Seizure: Lab

11. J. Stephen Huff, MD 11 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.

12. J. Stephen Huff, MD 12 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?

13. J. Stephen Huff, MD 13 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.

14. J. Stephen Huff, MD 14 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

15. J. Stephen Huff, MD 15 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?

16. J. Stephen Huff, MD 16 New-Onset Seizure: CT Which new-onset seizure patients who have returned to a normal baseline require a head CT scan in the ED?

17. J. Stephen Huff, MD 17 New-Onset Seizure: CT Level A recommendations - None

18. J. Stephen Huff, MD 18 New-Onset Seizure: CT Level B recommendations 1.When feasible, perform neuroimaging of the brain in the ED on patients with a first-time seizure. 2.Deferred outpatient neuroimaging may be used when reliable follow-up is available.

19. J. Stephen Huff, MD 19 New-Onset Seizure: CT The policy suggests that imaging may be deferred in this patient. Would you do anything different?

20. Picture

21. J. Stephen Huff, MD 21 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.

22. J. Stephen Huff, MD 22 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

23. J. Stephen Huff, MD 23 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?

24. J. Stephen Huff, MD 24 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?

25. J. Stephen Huff, MD 25 Level A recommendations - None Level B recommendations - None New-Onset Seizure: Admission

26. J. Stephen Huff, MD 26 Level C recommendations 1.Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up. 2.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. New-Onset Seizure: Admission

27. J. Stephen Huff, MD 27 New-Onset Seizure: Admission The policy suggests that this patient may be discharged for outpatient follow-up without starting on medications… Do you agree?

28. J. Stephen Huff, MD 28 Level C recommendations 1.Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up. 2.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. New-Onset Seizure: Admission

29. J. Stephen Huff, MD 29 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

30. J. Stephen Huff, MD 30 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

31. J. Stephen Huff, MD 31 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.

32. J. Stephen Huff, MD 32 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?

33. J. Stephen Huff, MD 33 Level A recommendations –None specified Level B recommendations –None specified Effective Dosing: Phenytoin

34. J. Stephen Huff, MD 34 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.

35. J. Stephen Huff, MD 35 Case 4 What would you do? –IV phenytoin or fosphenytoin? –PO phenytoin loading strategy? How? –Resume medications?

36. J. Stephen Huff, MD 36 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

37. J. Stephen Huff, MD 37 Effective Dosing: Phenytoin Commentary- No data exist to rationally guide therapy The risk of early seizure recurrence in this patient population is not known

38. J. Stephen Huff, MD 38 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.

39. J. Stephen Huff, MD 39 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

40. J. Stephen Huff, MD 40 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?

41. J. Stephen Huff, MD 41 Status Epilepticus: Refractory Level A recommendations –None specified Level B recommendations –None specified

42. J. Stephen Huff, MD 42 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.

43. J. Stephen Huff, MD 43 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?

44. J. Stephen Huff, MD 44 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

45. J. Stephen Huff, MD 45 Status Epilepticus: Refractory Commentary- Many options possible without clear superiority of one regimen Midazolam infusion Propofol infusion

46. J. Stephen Huff, MD 46 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

47. J. Stephen Huff, MD 47 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

48. J. Stephen Huff, MD 48 EEG in ED When should EEG testing be performed in the ED?

49. J. Stephen Huff, MD 49 EEG in ED Level A recommendations –None specified Level B recommendations –None specified

50. J. Stephen Huff, MD 50 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.

51. J. Stephen Huff, MD 51 Case 6 The clinical policy intimates that an emergency EEG should be considered What would you do in this case?

52. J. Stephen Huff, MD 52 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…

53. J. Stephen Huff, MD 53 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

54. J. Stephen Huff, MD 54 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.

55. J. Stephen Huff, MD 55 Key Learning Points Reviewed ACEP Clinical Policy Showed interactions with clinical world….

56. J. Stephen Huff, MD 56 Questions?? www.ferne.org www.ferne.org ferne@ferne.org J. Stephen Huff, MD jshuff@virginia.edu ferne_2005_aaem_france_huff_szfinal_fshow.ppt 8/29/2005 1:00 AM