On April 17, 2024, the ACEP Board of Directors approved a clinical policy developed by the ACEP Clinical Policies Committee on the management of adult patients presenting to the emergency department with seizures. This clinical policy was published in the July 2024 issue of the Annals of Emergency Medicine, can be found on ACEP’s website, and will also be included in the ECRI Guidelines Trust, upon its acceptance.

Patients presenting with seizure account for about 1% of all emergency department patients. First-line treatment for recurrent seizures is the appropriate dosing of benzodiazepines with second-line treatment including agents such as phenytoin, levetiracetam, and valproic acid. This latest clinical policy from the ACEP Clinical Policies Committee readdresses the critical question from the 2014 clinical policy regarding appropriate second-line agents in patients with refractory seizures in the emergency department that have been appropriately dosed with benzodiazepines.

The critical question was based on feedback from ACEP membership. A systematic review of the evidence was conducted, and the committee made recommendations (Level A, B, or C) based on the strength of evidence available. This clinical policy underwent internal and external review expert review and was available for review by ACEP membership during an open comment period. Responses received were used to refine and enhance the final policy.

CRITICAL QUESTION

In emergency department patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of benzodiazepine, which agent or agents should be administered next to terminate seizures?

Patient Management Recommendations

Level A recommendations. Emergency physicians should treat seizures refractory to appropriately dosed benzodiazepines with a second-line agent. Fosphenytoin, levetiracetam, or valproate may be used with similar efficacy.

Level B recommendations. None specified.

Level C recommendations. None specified.

Translation of Classes of Evidence to Recommendation Levels

Based on the strength of evidence for the critical question, the subcommittee drafted the recommendations and supporting text synthesizing the evidence using the following guidelines:

Level A recommendations. Generally accepted principles for patient care that reflect a high degree of scientific certainty (eg, based on evidence from one or more Class of Evidence I or multiple Class of Evidence II studies that demonstrate consistent effects or estimates).

Level B recommendations. Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate scientific certainty (eg, based on evidence from one or more Class of Evidence II studies or multiple Class of Evidence III studies that demonstrate consistent effects or estimates).

Level C recommendations. Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.

Dr. Smith was born, raised, and trained in Ohio, and relocated to the heat and constant party of New Orleans, Louisiana. His academic interests are simulation and student and resident education. He has been active in organized emergency medicine including many ACEP committees and is the past president of the Ohio Chapter of ACEP, the Louisiana Chapter of ACEP, and the Simulation Academy of SAEM.