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The Management of Seizures and SE in the Emergency Department. Edward Sloan, MD, MPH, FACEP. Associate Professor & Research Development Director Department of Emergency Medicine, University of Illinois at Chicago Chicago, IL ( Global Objectives.

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The Management of Seizures and SE in the Emergency Department

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The management of seizures and se in the emergency department

The Management of Seizures and SE in the Emergency Department

Edward sloan md mph facep

Edward Sloan, MD, MPH, FACEP

Associate Professor &

Research Development Director

Department of Emergency Medicine, University of Illinois at Chicago

Chicago, IL


Global objectives

Global Objectives

  • Learn more about seizures

  • Increase awareness of Rx options

  • Enhance our ED management

  • Improve patient care & outcomes

  • Maximize staff & patient satisfaction

  • Be prepared for the EM board exam

Session objectives

Session Objectives

  • Provide seizure and SE overview

  • Summarize what Rx options exist

  • Discuss specific sub-groups

  • Outline ED Rx strategies

Sz epidemiology

Sz Epidemiology:

  • Epilepsy seen in 1/150 people

  • For each epilepsy pt, 1 ED visit every 4 years

  • 1-2% of all ED visits

  • Significant costs

Seizure mechanism

Seizure Mechanism:

  • Sz = abnormal neuronal discharge with recruitment of otherwise normal neurons

  • Loss of GABA inhibition



  • Glutamate toxic mediator

  • Necrosis occurs even if systemic problems are treated (HTN, fever, rhabdomyolysis, resp acidosis, hypoxia)



  • Early compensation for increased CNS metabolic needs

  • Decompensation at 40-60 minutes, associated with tissue necrosis

Seizure classification

Seizure Classification:

  • Generalized: both cerebral hemispheres

  • Partial: one cerebral hemisphere

Generalized seizures

Generalized Seizures :

  • Convulsive: tonic-clonic

  • Non-convulsive: absence

Generalized seizures1

Generalized Seizures :

  • Primary generalized: starts as tonic-clonic seizure

  • Secondarily generalized: tonic-clonic seizure occurs as a consequence of a non-convulsive seizure

Partial seizures

Partial Seizures :

  • Simple partial: no impaired consciousness

  • Complex partial: impaired consciousness

Specific seizure types

Specific Seizure Types :

  • Absence: Petit mal

  • Partial: Jacksonian, focal motor

  • Complex partial: temporal lobe, psychomotor

Status epilepticus

Status Epilepticus:

  • Sz > 5- 10 minutes = SE

  • Two sz without a lucid interval = SE (Assumes ongoing sz during coma)

Se epidemiology

SE Epidemiology:

  • Risk of SE greatest at extremes of age: pediatric and geriatric populations

  • SE: occurs in setting of acute insult, chronic epilepsy, or new onset seizure

  • 150,000 cases per year

Se classification

SE Classification:

  • GCSE: Generalized convulsive SE, with tonic-clonic motor activity

  • Non-GCSE

Two non gcse types

Two Non-GCSE Types:

  • Non-convulsive SE

    • Absence SE

    • Complex-partial SE

  • Subtle SE

    • Late generalized convulsive SE

    • Coma, persistent ictal discharge

    • Very grave prognosis

Ams in seizures

AMS in Seizures:

  • Mental status should improve by 20-40 minutes

  • If pt comatose, then subtle SE is possible: EEG

  • Up to 20% of pts with coma still are in SE

Ongoing se effects

Ongoing SE Effects:

  • Over 40-60 min, loss of metabolic compensation

  • With ongoing SE, systemic BP & CBF drop

Se mortality

SE Mortality:

  • SE mortality > 30% when sz longer than 60 minutes

  • Underlying sz etiology contributes to mortality

Subtle se

Subtle SE:

  • Mortality exceeds 50%

  • Often after hypoxic insult

  • Coma

  • Limited motor activity

  • Stop the sz, EEG confirm

General ed management

General ED Management:

  • ABCs

  • Glucose, narcan, thiamine

  • Rapid sequential use of AEDs

  • Directed evaluation

Lab evaluation

Lab Evaluation:

  • Key lab abnormality: hypoglycemia, in up to 2%

  • Directed labs, including anti-epileptic drug levels

Lumbar puncture

Lumbar Puncture:

  • Fever and CSF pleocytosis can occur in SE without meningitis

  • Use clinical criteria to determine LP need

  • AMS, immunocompromise, meningismus

Neuroimaging with ct

Neuroimaging with CT:

  • CT useful with focal sz, change in sz type or frequency, co-morbidity

  • Req’d in new-onset sz

  • Non-contrast unless mass lesion suspected

Neuroimaging with mri

Neuroimaging with MRI:

  • Useful with refractory sz

  • Complements plain CT

  • Can be done as outpt

Eeg monitoring

EEG Monitoring:

  • EEG to rule out subtle SE

  • Prolonged coma, RSI, induced coma with propofol, pentobarbital

  • Obtain EEG in 120 minutes

  • Two-lead EEG in ED

Aed loading

AED loading:

  • Repeated seizures, high-risk population, significant SE risk

  • No need to determine level in ED after loading

  • Oral loading in low risk pts

Hospital admission

Hospital Admission:

  • Repeated sz, high-risk pt, significant SE risk

  • Esp if no AED loading

  • New-onset seizure: admission is preferred (complete w/u, observe)

New onset sz recurrent sz

New-Onset Sz: Recurrent Sz

  • 51% recurrence risk

  • 75% of recurrent sz occur within 2 years of first sz

  • Only a small % of pts will seize within 24 h

  • Partial sz, CNS abn inc risk

Ed discharge

ED Discharge:

  • Follow-up & EEG needed, esp if no AED prescribed

  • Driving documentation is critical. Know state law.

Pharmacotherapy of seizures

Pharmacotherapy of Seizures

  • Benzodiazepines

  • Phenytoins

  • Barbiturates

  • Other agents

    • valproate

    • propofol

General aed concepts

General AED Concepts:

  • Most drugs are at least 80% effective in Rx seizures, SE

  • Have AEDs available in ED

  • Maximize infusion rate in SE

  • Use full mg/kg doses



  • GABA drug

  • Diazepam: short acting, limited AMS and protection

  • Lorazepam: prolonged AMS and protection

  • Pediatric sz: IV lorazepam limits respiratory compromise

Rectal diazepam

Rectal Diazepam:

  • Diazepam rectal gel pre-packaged for rapid use

  • Dose 0.5 mg/kg, less respiratory depression seen than with IV use



  • Phenytoin: Na+ channel Rx

  • Load at 18 mg/kg, 1.5 doses

  • Infuse at 50 mg/min max

  • Use pump to prevent comp

  • Level 10-20 µg/mL



  • Fos: pro-drug, dose same

  • Infuse at 150 mg/min in SE

  • Can be given IM up to 20cc

  • Level 10-20 µg/mL

  • Delayed level: 2h IV, 4 h IM

Iv phenobarbital

IV Phenobarbital:

  • GABA-like, effective sz Rx

  • Limited availability

  • Infuse up to 50 mg/min

  • 20-30 mg/kg, 10 mg/kg doses

  • Level > 40 µg/mL

Iv valproate

IV Valproate:

  • Likely GABA mechanism

  • Useful in peds, possibly SE

  • Rate up to 300 mg/min

  • 25-30 mg/kg, 3-6 mg/kg/min

  • Level > 100 µg/mL

Refractory se

Refractory SE:

  • SE refractory to benzos, phts, phenobarb, valproate

  • Propofol, pentobarb: useful third line agents

  • Midazolam infusion also useful

  • Respiratory depression, BP

  • Must control airway, get EEG

Iv propofol

IV Propofol:

  • Likely GABA mechanism

  • Provides burst suppression

  • 2 mg/kg loading dose

  • Hypotension, resp depression, acidosis

  • Easily reversed

Iv pentobarbital

IV Pentobarbital:

  • Likely GABA mechanism

  • Provides burst suppression

  • 5 mg/kg loading dose

  • 25 mg/kg infusion rate

  • ICU monitoring required

Ed treatment protocol

ED Treatment Protocol:

  • Have AEDs easily available

  • Rapid sequential AED use

  • Maximize infusion rate

  • Maximize mg/kg dosing

  • Benzos, phenytoins, phenobarbital, valproate

No iv access

No IV Access:

  • PR diazepam

  • IM midazolam

  • IM fosphenytoin

  • Buccal, intranasal midazolam

  • No IM phenytoin/phenobarbital

Special populations

Special Populations

  • Drug and alcohol-related seizures

  • Acute CVA

  • Post-traumatic

  • Pregnancy

  • Pediatrics

  • Elderly

  • Psychogenic seizures

Drug related sz

Drug-related Sz:

  • Stimulants, anti-depressants, theophylline and cocaine commonly can cause sz

  • Most sz treated with benzos

  • Phenytoin less useful

Drug related sz rx

Drug-related Sz Rx:

  • INH: Blocks GABA production

    • Vit B6, pyridoxine

    • 5 gr IVP x 6, match ingestion gr

  • Theophylline: eliminate with hemodialysis, hemoperfusion

  • Tricyclics, cocaine: benzos,?? utility of other drugs

Etoh related seizures

EtOH-related Seizures:

  • Occur 12 hrs p last drink

  • Lorazepam optimal Rx for sz

  • Lorazepam in DTs and sz prevention

  • Phenytoin ?? sz flurries, SE

Seizures in acute cva

Seizures in Acute CVA:

  • Seizures can occur in stroke

  • Consider prophylaxis with elderly, large hemorrhage, anterior CVA location

Post traumatic seizures

Post-traumatic Seizures:

  • High-risk populations exist

  • Early prophylaxis stops early sz, not late sz onset

  • Phenytoins, valproate

Seizures in pregnancy

Seizures in Pregnancy:

  • Seizures related to changing AED levels and eclampsia

  • Benzos may be useful initially

  • Magnesium 4-6 g load, 1-2 g/hr

  • Respiratory depression, BP

Pediatric seizures

Pediatric Seizures:

  • Peds sz, SE in kids 0-3 yrs

  • Common ED problem

  • 80% are febrile sz

  • CNS abnormalities: afebrile sz

  • Cocaine, hyponatremia, meningitis

  • Outcome good, CNS plastic

Febrile seizures

Febrile Seizures:

  • 6 months to 5 years

  • Up to 50% repeat febrile sz

  • Increased risk if age < 1 yr

  • No increased epilepsy risk

  • Complex: focal, > 15 min duration, flurry of sz

Febrile seizure ed rx

Febrile Seizure ED Rx:

  • Limited need for LP

  • Sz as sole manifestation of meningitis not seen

  • HIB: meningitis rare

  • Treat bacteremia (WBC > 15k)

  • CBC, blood cx, ceftriaxone

Other pediatric sz types

Other Pediatric Sz Types

  • Neonatal seizures

  • Benign childhood epilepsy (Rolandic)

  • Infantile spasms (West syndrome)

  • Lennox-Gastaut syndrome

  • Atonic seizures

  • Juvenile myoclonic epilepsy (JME)

Juvenile myoclonic epilepsy

Juvenile Myoclonic Epilepsy:

  • Common in teens, young adults

  • Etiology of generalized TC seizures

  • History of staring spells, AM clumsiness, myoclonus

  • Sleep deprivation, EtOH precipitants

  • Valproate may be best acute Rx

Seizures in the elderly

Seizures in the Elderly:

  • AMS: non-convulsive SE

  • Drug-drug interactions

  • CVD, tumor, toxicities

  • Caution for hypotension, cardiac dysrhythmias, IV AED extravasation

Psychogenic sz

Psychogenic Sz:

  • Functional sz, not neurogenic

  • Conversion disorder, not faking it

  • Seen in 20% of epilepsy pts

  • Neurogenic sz in up to 60% of psychogenic sz pts: treat first!

  • Characteristic mvmts noted

Ems seizure rx

EMS Seizure Rx:

  • Sz cause recurrent EMS need

  • ALS care for CNS findings, unstable, high risk

  • Low risk fractures (BB/collar)

  • IV, PR diazepam

  • IM midazolam

Research in sz se

Research in Sz, SE:

  • Treiman D: VA Coop study

  • Alldredge B: PHTSE

  • Huff S: ED Sz epidemiology

  • EFA Working Group (JAMA)

  • Hampers L: Febrile sz ED Rx

Efa guidelines

EFA Guidelines:

  • Protocol: ABCs, know drugs, adequate doses

  • Benzodiazepines, phenytoins, phenobarb/valproate

  • Midazolam, propofol, pentobarb

  • Specify general timelines

Se rx timeline

SE Rx Timeline:

  • 0-30 min: ABCs, benzos

  • 30-45 min: Phenytoins

  • 45-75 min: Phenobarb/valproate

  • 75+ min: Refractory SE Rx

  • 90-150 min: CT, EEG, ICU/OR

Acep cpc questions

ACEP CPC Questions

  • Clinical Policy Committee

  • Written guidelines

  • Clinically relevant questions

    • Role of oral loading

    • Subtle SE, EEG use

    • Post-benzo AED therapy in SE

    • New onset seizure ED Rx

Sz se conclusions

Sz, SE Conclusions

  • Sz, SE: medical emergencies

  • Early Rx is critical

  • Many Rx options exist

  • Maximize ED Rx

    • Have a plan

    • Have meds readily available

    • Use EEG when indicated

Slide content

Slide Content

  • Slides on FERNE website

  • EM physicians, neuro emergencies


  • Look for button on main page

  • 2001 ICEP Seizure Lecture

Ferne sz symposium

FERNE Sz Symposium

  • Tuesday October 16, 2001

  • 4:00 to 6:00 pm

  • U of Chicago Gleacher Center

  • Clinical Issues in ED Seizure Rx

  • Register online at

  • Login