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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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
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