Several states (California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania) have mandatory reporting laws.

Known Seizure Disorder

In patients with a known seizure disorder, a head CT scan should be considered for patients with new focal deficits, significant trauma, persistent fever, new pattern of seizure, or suspicion of AIDS, infections, or anticoagulation. Blood levels of pertinent medications should be obtained.

If antiepileptic medication blood levels are found to be low, a loading dose is given in the emergency department. Levels of phenytoin, carbamazapine, phenobarbital, and valproic acid are readily available in the emergency department.

Phenytoin is classically given as 1 g in the emergency department, with half of the medication being given orally and half intravenously, but this may be subtherapeutic in obese patients or patients with difficult-to-control seizures. Oral administration alone is cheaper than the IV route and can achieve therapeutic levels when given in appropriate doses (19 mg/kg in men and 23 mg/kg in women) divided every 2-4 hours at 400-600 mg per dose to minimize GI and neurologic side effects.^7,8

Fosphenytoin is the preferred drug if given intravenously (to avoid the complications of the propylene glycol diluent of phenytoin) and can be given at a dose of 15-20 phosphenytoin equivalents (PE)/kg.

Valproic acid or phenobarbitol can be given as a parenteral loading dose of 20 mg/kg, but this is not recommended for phenobarbital in the awake, alert, nonseizing patient because of the heavy sedative effects of phenobarbital.

Carbamazepine is not recommended to be loaded orally because of the high rates of adverse events.⁹

Levetiracetam is one of the newest antiepileptic medications. Levels cannot be readily checked in the emergency department, but because of its wide therapeutic index, it is generally considered safe to give in the ED without knowing the patient’s compliance. (See box for dosing.)

Overall, even with therapeutic levels, up to 50% of patients with epilepsy will have recurrent seizures despite medical therapy.⁴

Pregnancy

Eclampsia is defined as a new onset of grand mal seizure activity (and possible coma) during pregnancy or post partum (up to 4 weeks after delivery). Magnesium sulfate should be administered to prevent subsequent seizures. It is given intravenously as a loading dose of 4-6 g over 20 minutes with a maintenance dose of 1-2 g/h as continuous IV infusion. For patients who continue to have seizure activity while receiving magnesium, seizures can be treated with benzodiazepines.