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As relieved as we are that the Ebola outbreak appears to be limited and less of a daily concern in our emergency departments, we do still remain on alert for the outbreak of other infectious diseases. It’s been very gratifying to see several ACEP members who are subject matter experts in infectious disease step up and help us create the resources we’ve posted on ACEP.org for the entire emergency medicine community. Among those experts are Kristi Koenig and Carl Schultz from the University of California at Irvine. They’re working on a new edition of their book on disaster medicine and realized that the chapter on emerging infectious diseases would be very useful to us all right now. As they said,
“The emergency health care system must be prepared for an evolving public health event of international significance such as this. Emergency physicians are on the front lines and should be knowledgeable, up-to-date, and ready to effectively manage infectious disease threats. It doesn’t matter whether such threats arise from Ebola virus disease, Enterovirus D-68, MERS-CoV, SARS, the 2009 H1N1 pandemic, or the next big event, as yet unnamed. We should be leaders in our hospitals, EMS systems, and communities, advocating for protection of the public health, our patients, and colleagues.”
Kristi and Carl have donated a preliminary electronic draft of that chapter to the College – to all of you, really – as a resource to help you and your team prepare to screen for and treat the wide range of infectious diseases any of us could see any day of the week.
Just follow this link to download the chapter now.
Best wishes to you all, and be well. We hope to see you next week in Chicago for ACEP14.
Alex M. Rosenau, DO, CEP, FACEP
Micahael J. Gerardi, MD, FAAP, FACEP
With so much information and speculation being circulated about Ebola presentations in the United States, I want you – our members – to know what your College is doing on this issue.
The landscape about treatment and containment of this infectious disease is changing minute by minute. ACEP has been working in many ways to filter the information and provide you with a trusted source of updates. We also have many initiatives planned for next week, next month and beyond as we continue to help you in these challenging times and be a supportive advocate for our specialty and our patients. Advocating for your safety and making sure you have everything you need are our most important goals.
Here are some of the things we are doing:
- Immediately convene a panel of 8 emergency care infectious disease experts.
- Review materials pertinent to emergency care for dissemination to members.
- Respond to questions posted by members via an easily accessible form on the www.acep.org/ebola resource page.
- Develop repository of best practices for managing the patient with suspected and confirmed Ebola and work with CDC, WHO, and other federal, state and local agencies to develop protocols that can be implemented in hospitals with limited resources. Update the content regularly.
Resources on ACEP Website
- Consolidation of pertinent resources, including those from the Expert Panel, on www.acep.org/ebola with frequent updates.
- Continue to promote availability of resources through social media, e-newsletters and other communication vehicles.
Identify short and long-term legislative initiatives designed to assist our members and other health care providers to enhance their disaster preparedness:
- Advocate for regionalization protocols
- Enactment of trauma systems/emergency regionalization legislation
- Funding of a national grid of bio-containment hospital annexes,
- Increase funding for disaster preparedness
- Increase supplies of PPEs
- Additional resources for training and retention of first responders
- Good Samaritan liability protection for first responders in a national emergency
Communications with Members
- EM Today curates the media daily for a round-up of the most pertinent articles and editorials.
- Immediate dissemination of important information through social media, e-newsletters and stand-alone messages.
- Section listservs include the latest updates and guidelines from CDC to some of the most impacted sections – Air Medical Transport, Disaster Medicine, EMS-Prehospital Care, and Tactical Emergency Medicine.
- EMS Committee review of CDC guidelines to consider operational ‘suggestions’ on meeting the requirements or model practices.
Communication with the Public and the News Media
- Linking reporters with ACEP experts in infectious disease and disaster preparedness. ACEP is managing 10 to 20 calls a day from reporters on this issue. (a round-up of ACEP spokesperson in the news can be found at http://www.acep.org/Content.aspx?id=80956)
- Coordinated editorial about Ebola response for ACEP President Dr. Alex Rosenau published in USA Today.
- Developed talking points for use by ACEP spokespersons to conduct press interviews.
- Using responses from ACEP infectious disease and preparedness experts to craft public messages.
- New course on Ebola infection and emergency department response added to ACEP14 — “Ebola: Hemorrhagic Fever and the U.S. Experience” will be presented Tuesday, October 28, during ACEP14, the world’s largest meeting of emergency physicians.
- ACEP14 Ebola Courses – Three presentations from ACEP14, October 27-30, will be captured live and presented as free courses in ACEP eCME, the College’s online and mobile education platform to members and other EM colleagues. Each of the three courses will have a pretest, an audio and slide presentation of the lecture as it was delivered live in Chicago, and a post-test. Each of the courses also is approved for AMA PRA Category 1 Credit.™The courses are:
- Inside the Hot Zone: Highly Infectious Pathogens in the ED / David C. Pigott, MD, RDMS, FACEP, will identify those pathogens—including Ebola and anthrax—that are most likely to be encountered in the ED as well as those that present the greatest risk for health care providers and other personnel. This case-based review will include a discussion of appropriate barrier precautions, including personal protective equipment, as well as departmental and hospital-based infectious disease transmission precautions.
- Ebola: Hemorrhagic Fever and the U.S. Experience / David C. Pigott, MD, RDMS, FACEP; and Alexander P. Isakov, MD, FACEP will discuss the risk factors for exposure to the Ebola virus, the clinical features associated with, and considerations for, evaluation and management of patients with suspected or confirmed Ebola virus disease (EVD). They will highlight the most recent recommendations for infection control and prevention applicable for healthcare workers in both the out-of-hospital (EMS) and emergency department setting. Participants will be provided a framework that permits the delivery of optimal care to this special patient population while minimizing risk to members of the healthcare team.
- Infections From Abroad: Unwanted Souvenirs / Ever heard about “airport malaria?” Should you be worried about that “funny rash” on the Ugandan businessman? What medical advice do you give your sister who is planning a trip to Vietnam? Swaminatha Mahadevan, MD, FACEP, will identify infectious hotspots around the world and highlight “must-know facts” about travelers and visitors from these areas. In addition, find out what precautions travelers should consider as they plan their next great adventure abroad.
- “Emerging Infectious Diseases: Concepts in Preparing for and Responding to the Next Microbial Threat” – Two of the nation’s experts in disaster medicine, Kristi Koenig, MD, FACEP, and Carl Schultz, MD, FACEP, along with Cambridge University Press, have donated the “rough cut” of this chapter from the second edition of their book, Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practice to help emergency physicians care for patients with a wide variety of emerging and re-emerging infectious diseases. It will be posted on the ACEP Ebola Resources page (www.acep.org/ebola) by Oct. 24, 2014. The chapter covers many diseases and a variety of issues such as resource allocation, preparedness training exercises, personnel, communications, and much more.
- “Innovations in Patient Safety Presented by ACEP, Urgent Matters, and the Emergency Medicine Patient Safety Foundation” is a 5-hour conference scheduled for Sunday, Oct. 26, in Chicago. It will be captured live, and the portions addressing error prevention in the care of infectious diseases such as Ebola will be made available as another free educational resource.
- “ACEP Advanced EMS Practitioners’ Forum and Workshop” is another education event scheduled for Oct. 26, in conjunction with ACEP14. It, too, will be recorded so that information related to prehospital response and precautions in infectious disease can be disseminated to a larger audience. There will be three presentations on Ebola and the Dallas experience.
- “Fighting Ebola by Design” is a 10-minute EDTalk in the innovatED space presented by HKS/MI2. These companies were involved in Project ER One, which was federally funded to develop design features for ED’s to address terrorism, disaster and epidemics of emerging diseases. Innovative design features developed for ER One will be presented, as well as how one can mitigate the risk of infection transfer. Key features of design and new technology will be discussed. This talk will be videotaped and made available to the public as soon as possible after the conference.
- Ebola response survey being developed for dissemination through our Emergency Medicine Patient Safety Network (EMPRN) to gather data on preparedness for Ebola, EV-D68 and other infectious diseases. Members will be asked about their need for education/resources/assistance from ACEP and/or government sources to effectively respond to an Ebola case in their hospital.
- Surveyed the Disaster Medicine Section, EMS Committee and Section and ACEP infectious disease experts about response needs and preparedness
Work with Other Organizations
- Meet with high-level officials at the CDC.
- Convene a meeting(s) with the American Hospital Association, Emergency Nurses Association, National Association of EMS Physicians, Emergency Medicine Residents’ Association, and other key stakeholders for information/resource sharing.
- Work with additional federal agencies, such as National Institutes of Health, Assistant Secretary for Preparedness and Response, Emergency Care Coordination Center, Department of Homeland Security, and National Highway Traffic Safety Administration, to develop resources for infectious disease response.
- Share information with top officers of the American Medical Association and other groups.
Regionalization will be a key discussion point in all conversations.
Alex M. Rosenau, DO, CPE, FACEP
Click here to get the shiny new October issue of the audio/podcast for Annals of EM.
-Patient satisfaction: is it a marker of quality care? NOPE
-Pediatric appendicitis: can EPs accurately use bedside sono?
-Navigating online EM resources: 5 tips
-Steroids for bronchiolitis: yes or no
Enjoy the ACEP 2014 SA in Chicago, find us and say ‘hello’. Also, email firstname.lastname@example.org any time.
ps We forgot to post it on Central Line, but Sept is up as well — download and listen, it’s a good one.
Emergency physicians from top organizations representing emergency medicine traveled to Washington, DC, this week to meet with Ben Harder, managing editor and director of health care analysis at US News & World Report and Dr. Nate Gross, co-founder of Doximity, an online social networking service for U.S. physicians that conducts surveys for US News.
The purpose of these meetings was to convey the concerns of nine emergency medicine organizations about the results of a Doximity survey, which was promoted by US News & World Report, identifying the nation’s top emergency medicine residency programs.
Prior to the meeting, emergency physicians from the nine organizations held a conference call and developed a joint letter to US News and Doximity challenging the sampling method and the implications of providing misleading information to medical students and the public.
Four physicians represented the group at these meetings:
- Hans R. House, MD, FACEP, ACEP board member
- Jeffrey N. Love, MD, MSC, president, Council of Emergency Medicine Residency Directors
- Jordan Celeste, MD, president, Emergency Medicine Residents’ Association
- Mark Mitchell, DO, FACOEP, president, American College of Osteopathic Emergency Physicians
During the meetings, the physicians conveyed that the results:
- Are misleading to medical students because they are not based on objective criteria.
- Are not useful to medical students because residency choices are made for many reasons, including geography, which are not factors in the Doximity survey.
- Are not an accurate portrayal of residency programs because they are based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended.
- Do not reflect the unique nature of emergency medicine.
- Send a dangerous public health message to patients having medical emergencies.
The physicians conveyed there is potential value in a secure data service for communicating HIPAA-compliant messages among emergency physicians. Also, a resource that provides detailed information on residency programs and their alumni could help medical students in making decisions about their applications to specialty training. However, the collective organizations that represent all of emergency medicine could not support the data as long as the rankings were included. Both US News and Doximity agreed there were significant limitations of the data and discussed the challenges of developing objective measures for emergency medicine, because it is a unique medical specialty. Both also agreed that these data would not be promoted to the general public.
The editor at US News described the new organiza
tion’s publications that rank hospitals and medical specialties as “consumer decision support,” which are intended to help members of the general public make decisions about where to seek care for complex medical problems. Emergency medicine has never been included in these rankings in the past, and there are no plans to begin doing so. The editor conveyed that US News recognizes that, in a medical emergency, the best place to get care is the nearest emergency department.
The physicians asked to provide a companion piece to the US News article about the results. The editor agreed to review and publish, if acceptable. The co-founder of Doximity offered to discuss these issues with leaders in his organization and suggested further discussion at ACEP 14 in Chicago.
The following organizations are participating in this effort:
- American College of Emergency Physicians
- American Academy of Emergency Medicine
- American Academy of Emergency Medicine Resident and Student Association
- American Board of Emergency Medicine
- American College of Osteopathic Emergency Physicians
- Association of Academic Chairs of Emergency Medicine
- Council of Emergency Medicine Residency Directors
- Emergency Medicine Residents’ Association
- Society for Academic Emergency Medicine
ACEP and the leaders of other medical specialties representing emergency medicine, have taken issue with a recent survey of emergency medicine residency programs, by US News & World Report and Doximity. Below is a letter from Dr. Rosenau to US News & World Report.
September 12, 2014
Mr. Ben Harder
Managing Editor and Director
Health Care Analysis
US News & World Report
105 Thomas Jefferson Street, NW
Washington, DC 20007
Dear Mr. Harder:
As leaders of the top organizations representing emergency medicine, we have been contacted by scores of emergency physicians from around the country about a survey being conducted by Doximity and publicized by US News and World Report. We appreciate your recognition of emergency medicine as an academic medical specialty with a unique core of knowledge and robust research agenda.
However, we are concerned about the sampling method chosen for this survey, because we believe it will fail to achieve your objective for this survey — to identify America’s top emergency medicine training programs. Asking only physicians enrolled in a social media website to nominate their five most preferred residencies will result in egregious sample bias and is not capable of resulting in a scientifically valid result. The results will be based solely upon opinions expressed by physicians who have no first-hand knowledge of any residency training programs other than the ones they attended themselves.
While not a formal ranking of residency programs, the results would convey that some programs provide better training than others. However, given the limitations, this would not be an accurate portrayal — to medical students or to the public. It also would not be useful to many medical students, because research shows that more than 75 percent of emergency physician residents report the number one reason for selecting a residency program is geography.
More concerning, the results could send a dangerous public health message to people with medical emergencies. It implies they should consider bypassing hospital emergency departments with residency programs that fared poorly in the survey. In a medical emergency, people should seek emergency care at the nearest emergency department, not one that scored better on a highly subjective opinion survey.
Patients need confidence in their physicians in times of crisis, especially since comparison shopping among doctors is not an option when someone is having a medical emergency. Emergency medicine residency programs train physicians in the emergent and acute conditions of just about every medical specialty in health care. As a result, emergency physicians are uniquely qualified to handle a full range of adult and pediatric emergencies. In addition, they see every kind of human drama imaginable, often treating multiple patients at a time.
The overall quality of medical care delivered in emergency departments in the United States is excellent, thanks to the uniformly high standards that govern the accreditation of residency programs in emergency medicine. Emergency medicine residencies collaborate openly with shared curricular tools built around a core model of clinical practice, an approach that is fairly unique in medical education. Ranking training programs above others is contrary to the principles of our specialty, although we recognize that certain programs are best suited for certain trainees.
Many factors contribute to a successful residency program, not all of which can be measured or compared. If your target audience is medical students contemplating a career in our field, we would be happy to work with you to identify objective, measurable factors to help students find the best program for their individual needs.
Unfortunately, our organizations, which represent more than 40,000 emergency physicians, could not recommend or encourage participation in the current survey by emergency physicians. We would, however, be happy to meet with you and help to identify the parameters that might better accomplish that purpose. If you are interested, please contact Marjorie Geist at 800-798-1822, ext. 3290.
Alex M. Rosenau, DO, CPE, FACEP
President, American College of
Meaghan Mercer, MD
President, American Academy of Emergency
Medicine Resident and Student Association
Mark Mitchell, DO, FACOEP
President, American College of Osteopathic
Jeffrey N. Love, MD, MSc
President, Council of Emergency Medicine
Jordan Celeste, MD
President, Emergency Medicine Residents’
cc: Avery Comarow, Health Rankings Editor
By Andrew E. Sama, MD, FACEP
With nearly two-thirds of all admitted septic patients presenting to the ED, and with the clear time sensitivity that exists between recognition, treatment, and outcomes, our members are on the front lines to save lives from this frequently fatal disease. In the CY 2015 IPPS rule, in which CMS cited the fact that “that patients admitted through the ED had a 17% lower likelihood of dying from sepsis than when directly admitted,” CMS finalized NQF #0500: Early Management Bundle for Severe Sepsis and Septic Shock, which mandated the invasive monitoring of CVP and ScVO2 via the placement of a central line in the ED. However, late on Friday, CMS notified hospitals, that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice.
Emanuel Rivers, MD, MPH, and his team improved mortality and raised the awareness of the EM community about sepsis through their Early Gold Directed Therapy (EGDT) study in the early 2000s. A few years later, the measure was initially endorsed by the NQF in 2008 without the requirement for a central line for the emergency department. While it is certain that early intervention does reduce mortality, not all elements of the sepsis composite bundle were equally evidence-based. Many studies over the years have demonstrated dramatic improvements in sepsis-related mortality after the implementation of early interventions for septic patients, which included early antibiotic administration, source control, and aggressive fluid resuscitation without invasive monitoring of CVP and ScVO2. One study addressing this, authored by Dr. Alan Jones and colleagues, was conducted at three EDs in the US, and compared two protocols that both included central venous pressure measurement; however, one used lactate clearance and the other used central venous oxygenation monitoring as a way to guide resuscitation. Dr. Jones’ 2010 study found no differences in mortality, suggesting that using central venous oxygenation to guide resuscitation may not be necessary.
In 2012 the measure underwent routine NQF maintenance review for re-endorsement in 2012-2013. During those proceedings, under the leadership of David Seaberg, MD, FACEP and myself ACEP commented that central venous pressure (CVP) was not the only reliable measure of intravascular volume. Several members of ACEP’s Quality and Performance Committee (QPC) including chair Jeremiah D. Schuur, MD, MHS, FACEP, Michael Phelan, MD, RDMS, FACEP, Todd Slessinger, MD, FACEP, FCCM, FCCP, Christopher Fee, MD, FACEP, and others testified on conference calls and at in-person meetings, that there were equally effective and less invasive methods for monitoring septic patients. Nonetheless, the NQF endorsed the requirement for the central line, noting that they would re-consider if additional evidence warranted it.
Within a few months the Protocolized Care for Early Septic Shock (ProCESS) trial was published on March 18, 2014 and under Dr. Alexander Rosenau’s leadership ACEP immediately requested that NQF #0500 undergo an ad hoc review given the impact that this new data would have on this quality measure. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review, one of the PIs, Donald Yealy, MD, FACEP engaged in a scientific debate noting that the ProCESS trial enrolled 1,341 patients, with a power to detect a 6-7 percent absolute difference, yet demonstrated no difference in mortality 60-day mortality 90-day mortality, one year mortality, or the need for organ support. The ProCESS also noted no benefit in any outcome when using CVC- guided care and the simpler approaches that stressed early and ongoing care produced the same good outcomes.
CMS, NQF, and others are now also convinced that honing the sepsis bundle is a move forward for our septic patients, with or without invasive monitoring depending on the progression of their disease, their unique circumstances, and the resources available at the ED where they are being treated. As it is ACEP’s mission, we will continue to advocate on behalf of our patients presenting with a diagnosis of sepsis to ensure that they receive the highest quality of emergency care. We look forward to continuing to work with the measure developer to ensure that all septic patients receive the timely, effective care they need, and to continue to save lives from this deadly disease.
Dr. Sama is ACEP’s Immediate Past President and Chair of the Board of Directors
In a recent newsletter, the American Hospital Association informed its members of a change by CMS as it relates to data collection for severe sepsis and sepsis shock. Below is the CMS announcement.
The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program that it will suspend data collection for the Severe Sepsis and Septic Shock: Management Bundle measure (NQF #0500) until further notice. This measure was adopted for the FY 2017 payment determination in the CY 2015 IPPS final rule.
CMS continues to believe that this is an important area for measurement given mortality rates that range from 16-49% and that sepsis is one of the top 10 most common principle causes for hospitalizations. Further, through surveillance of early effective treatment of severe sepsis or septic shock, hospitals will not only know where in the sequence of steps to treat severe sepsis and septic shock patients, but also begin to decrease mortality related to sepsis and the costs associated with inefficient care of severe sepsis and septic shock patients. With this measure CMS will gauge if care of severe sepsis and septic shock patients is improving.
This measure was initially endorsed by the NQF in 2008 for the hospital/acute care facility setting and underwent routine NQF maintenance review for re-endorsement in 2013. During the 2013 NQF endorsement proceedings it was noted that should new data be published related to the measure, that the measure would undergo an ad hoc review. With publication of the Protocolized Care for Early Septic Shock (ProCESS) trial in early 2014, NQF #0500 underwent an ad hoc review to discern if the new data would impact the measure as currently designed. After reviewing the data from the ProCESS trial, NQF questioned whether NQF #0500’s item ‘F’, which measures central venous pressure and central venous oxygen saturation, should be retained or removed from the measure. During the review two other trials were identified that might also impact NQF #0500, those trials are the Australian Resuscitation in Sepsis Evaluation Randomized Controlled Trial (ARISE) and The Protocolised Management in Sepsis Trial (ProMISe). After much discussion of the results of the ProCESS trial, the potential impact the ARISE and ProMISe trials may have on the measure, and the recommendations to remove item ‘F’ from the measure, NQF recommended that measure stewards collaborate with other stakeholders to reach a compromise on NQF #0500’s item F. NQF recommended that measure developers collaborate with other stakeholders to reach a compromise on this specific element of NQF #0500 measure.
Given forthcoming research and NQF’s recommendations, with potential changes to the measure, CMS will delay data collection for the measure until further notice. The duration of this suspension pending further information from the measure developer has not yet been determined. This delay does not affect the data collection period for any other Hospital IQR Program measures.
July’s audio/podcast for Annals of EM is now posted here. Highlights:
-Early vs late rhythm analysis in OOHCA
-Ground based EMS transports and complications
-When do sepsis patients become septic? Usually NOT on arrival. Time to change the metric?
-Diethylene glycol outbreak
-Much, much more!
By Justin McNamee, DO; Nilesh Patel, DO; and Joseph Affortunato, DO
Department of Emergency Medicine
St. Joseph’s Regional Medical Center, Paterson, New Jersey
A 26-year-old woman presented to the emergency department, complaining of a 3-day history of lower abdominal pain and vaginal bleeding. She reported positive home pregnancy test results and that her last menstrual period was 17 weeks ago. On examination, the patient appeared comfortable and was afebrile, with a blood pressure of 131/67 mm Hg, pulse rate of 100 beats/min, and respiratory rate of 16 breaths/min.
Clinical Policy: Critical Issues in the Evaluation and Management
of Adult Patients Presenting to the Emergency Department With Seizures
By J. Stephen Huff, MD, FACEP
In the April 2014 issue of the Annals of Emergency Medicine, the American College of Emergency Physicians (ACEP) published a clinical policy focusing on seizures. This is a revision of a 2004 clinical policy with the same name.
This clinical policy can also be found on ACEP’s website www.acep.
This clinical policy takes an evidence-based approach to answering four frequently encountered questions with regards to decision making associated with seizures in the emergency department. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the Clinical Policies Committee’s well-established methodology:
Level A recommendations represent patient management principles that reflect a high degree of clinical certainty; Level B recommendations represent patient management principles that reflect moderate clinical certainty; Level C recommendations represent other patient management strategies based on Class III studies, or in the absence of any adequate published literature, based on consensus of the members of the Clinical Policies Committee.
During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, neurologists, and individual members of the American Epilepsy Society, the American Academy of Neurology, the Epilepsy Foundation of America, the National Association of Epilepsy Centers, and ACEP’s Quality and Performance Committee. The draft was also open to further comments through various ACEP communication pieces. All responses were used to further refine and enhance this policy; however, their responses did not imply endorsement of this clinical policy.
This revision of the clinical policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department focused on selected critical questions. Key to this policy revision was employing updated nomenclature for classification of seizures. Seizures can be thought of as provoked or unprovoked. Provoked seizures are secondary to electrolyte disturbances, toxins, infections, central nervous system mass lesions, withdrawal syndromes, or other etiologies. These provoked seizures, also known as acute symptomatic seizures, by definition occur at the time of or within seven days of acute neurologic, systemic, metabolic, or toxic processes. Unprovoked seizures occur in the absence of acute precipitating factors. Seizures from such processes as stroke, brain injury, and other CNS insults that occurred more than seven days in the past are also classified as unprovoked seizures. Epilepsy is defined by recurrent unprovoked seizures.
The question of initiating treatment with antiepileptic drugs for the adult patient presenting to the ED following a first generalized seizure who has returned to baseline clinical status was one critical question. The short-term recurrence risk of this group of patients is unknown but thought to be low. After literature review and grading the evidence, level C recommendations were developed for subgroups of patients. Appropriate clinical assessment by emergency physicians of patients is important since presumptive assignment of the seizure as provoked or unprovoked drives the treatment recommendation. However, it is unclear if seizures can be precisely identified as provoked or unprovoked using information available during an emergency department evaluation. Additionally, patient safety should remain a paramount concern for the practicing physician. Though the evidence supports discharging an adult patient who has returned to baseline status following a first unprovoked seizure, supporting articles assumed a safe support system for the discharged patient. Consideration of social issues or other factors may prompt consideration for admission.
Another critical question addressed treatment of ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine. There are remarkably few randomized prospective studies on this problem and none that consider the causes of status epilepticus. Large prospective studies are in the planning stages. Until these studies are completed, recommendations for specific drugs must reflect current lower levels of evidence. Many different medications are recommended and no medication or class of medications is clearly superior.
Designation of a seizure as provoked or unprovoked at some level is arbitrary and may change with the clinical course or as additional studies are performed. Emergency physicians play a critical role in determining whether a seizure is provoked or unprovoked. If there is an underlying medical condition, identification and treatment of that process is the primary consideration. It is hoped that future studies will focus on seizure recurrence of patients presenting to the ED with seizures, and study outcomes over days or another time frame relevant to emergency medicine.
Critical Questions and Recommendations
Question 1: In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?
Level C recommendations.
(1) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
(2) Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
(3) Emergency physicians may initiate antiepileptic medication* in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.
* Antiepileptic medication in this document refers to medications prescribed for seizure prevention.
Question 2: In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events
Level C recommendations. Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.
Question 3: In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures?
Level C recommendations. When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.
Question 4: In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures?
Level A recommendations. Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level B recommendations. Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Level C recommendations. Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
Dr. Huff is Professor of Emergency Medicine and Neurology, University of Virginia, Charlottesville, Virginia