The management of seizures and se in the emergency department
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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 ([email protected]). Global Objectives.

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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

([email protected])


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


Pathophysiology

Pathophysiology:

  • Glutamate toxic mediator

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


Pathophysiology1

Pathophysiology:

  • 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


Benzodiazepines

Benzodiazepines:

  • 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

Phenytoin:

  • 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


Fosphenytoin

Fosphenytoin:

  • 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

  • www.FERNE.org

  • 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 www.FERNE.org


  • Login