Management of breakthrough seizures in the emergency department: continuity of patient care

Headnote

Key words: Anticonvulsants - Continuity of patient care - Emergency service - Epilepsy - Hospital - Referral and consultation

ABSTRACT

Background: Epilepsy is a chronic disorder requiring long-term management. Communication between emergency physicians, neurologists, and primary care physicians (PCPs) is especially critical for the continuity of care for patients who present in an emergency department (ED) with a breakthrough seizure. Therefore, maximizing communication between the emergency physician and the PCP is of the utmost importance. The emergency physician, who is on the front line, must gather the information necessary to identify the underlying cause of the seizure and decide whether the pharmaceutical management must be changed.

Scope: This paper provides a clinical commentary on issues to consider when managing breakthrough seizures in the ED, to inform and facilitate communication between emergency physicians, consulting neurologists, and PCPs.

Conclusions: Clinical management decisions, especially when considering adjustment in an antiepileptic drug (AED) regimen, are often best made In coordination with a consulting neurologist. Increasing emergency physicians' comfort level regarding the use of newer-generation AEDs can improve the dialogue between the emergency physician and neurologist and the dialogue with the patient. Understanding the risks and benefits of the newer AEDs will assist the emergency physician in clinical decision making and, it is hoped, improve clinical outcomes. To preserve continuity of patient care, a patient's treating physician should be notified of all the particulars of the ED visit, and an appointment should be scheduled at the time of discharge for follow-up evaluation.

Introduction

The current prevalence of epilepsy in the United States is reported to be 1 % of the general population, or close to three million cases1,2. Unfortunately, approximately 20-30% of patients treated for epilepsy continue to experience seizures3,4. When breakthrough seizures occur in patients who are otherwise controlled, some seek medical attention first from an emergency physician rather than their treating neurologist or primary care physician (PCP).

Preserving continuity of care for patients experiencing a breakthrough seizure requires coordination with the physician who will assume care after the patient is discharged from die emergency department (ED). More often than not, communication with the outpatient physician at the time of discharge is incomplete or absent. To preserve the transition of care, emergency physicians should provide patients widi...