Clinical Policy: Critical Issues in the Evaluation
and Management of Adult Patients Presenting to
the Emergency Department With Seizures

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

Level B recommendations.
1. Determine a serum glucose and sodium level on
patients with a first-time seizure with no comorbidities
who have returned to their baseline.
2. Obtain a pregnancy test if a woman is of childbearing
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.

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

Level B recommendations.
1. When feasible, perform a 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.

III. 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?

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.

IV. 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?

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

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

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

VI. When should EEG testing be performed in the 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 a drug-induced coma.