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

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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

  • 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

  • Provide seizure and SE overview

  • Summarize what Rx options exist

  • Discuss specific sub-groups

  • Outline ED Rx strategies


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:

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

  • Loss of GABA inhibition


Pathophysiology:

  • Glutamate toxic mediator

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


Pathophysiology:

  • Early compensation for increased CNS metabolic needs

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


Seizure Classification:

  • Generalized: both cerebral hemispheres

  • Partial: one cerebral hemisphere


Generalized Seizures :

  • Convulsive: tonic-clonic

  • Non-convulsive: absence


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 :

  • Simple partial: no impaired consciousness

  • Complex partial: impaired consciousness


Specific Seizure Types :

  • Absence: Petit mal

  • Partial: Jacksonian, focal motor

  • Complex partial: temporal lobe, psychomotor


Status Epilepticus:

  • Sz > 5- 10 minutes = SE

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


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:

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

  • Non-GCSE


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:

  • 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:

  • Over 40-60 min, loss of metabolic compensation

  • With ongoing SE, systemic BP & CBF drop


SE Mortality:

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

  • Underlying sz etiology contributes to mortality


Subtle SE:

  • Mortality exceeds 50%

  • Often after hypoxic insult

  • Coma

  • Limited motor activity

  • Stop the sz, EEG confirm


General ED Management:

  • ABCs

  • Glucose, narcan, thiamine

  • Rapid sequential use of AEDs

  • Directed evaluation


Lab Evaluation:

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

  • Directed labs, including anti-epileptic drug levels


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:

  • 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:

  • Useful with refractory sz

  • Complements plain CT

  • Can be done as outpt


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:

  • 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:

  • 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

  • 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:

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

  • Driving documentation is critical. Know state law.


Pharmacotherapy of Seizures

  • Benzodiazepines

  • Phenytoins

  • Barbiturates

  • Other agents

    • valproate

    • propofol


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:

  • GABA drug

  • Diazepam: short acting, limited AMS and protection

  • Lorazepam: prolonged AMS and protection

  • Pediatric sz: IV lorazepam limits respiratory compromise


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: 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:

  • 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:

  • 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:

  • 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:

  • 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:

  • Likely GABA mechanism

  • Provides burst suppression

  • 2 mg/kg loading dose

  • Hypotension, resp depression, acidosis

  • Easily reversed


IV Pentobarbital:

  • Likely GABA mechanism

  • Provides burst suppression

  • 5 mg/kg loading dose

  • 25 mg/kg infusion rate

  • ICU monitoring required


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:

  • PR diazepam

  • IM midazolam

  • IM fosphenytoin

  • Buccal, intranasal midazolam

  • No IM phenytoin/phenobarbital


Special Populations

  • Drug and alcohol-related seizures

  • Acute CVA

  • Post-traumatic

  • Pregnancy

  • Pediatrics

  • Elderly

  • Psychogenic seizures


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:

  • 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:

  • 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 can occur in stroke

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


Post-traumatic Seizures:

  • High-risk populations exist

  • Early prophylaxis stops early sz, not late sz onset

  • Phenytoins, valproate


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:

  • 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:

  • 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:

  • 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

  • Neonatal seizures

  • Benign childhood epilepsy (Rolandic)

  • Infantile spasms (West syndrome)

  • Lennox-Gastaut syndrome

  • Atonic seizures

  • Juvenile myoclonic epilepsy (JME)


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:

  • AMS: non-convulsive SE

  • Drug-drug interactions

  • CVD, tumor, toxicities

  • Caution for hypotension, cardiac dysrhythmias, IV AED extravasation


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:

  • 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:

  • 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:

  • Protocol: ABCs, know drugs, adequate doses

  • Benzodiazepines, phenytoins, phenobarb/valproate

  • Midazolam, propofol, pentobarb

  • Specify general timelines


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

  • 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: 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

  • Slides on FERNE website

  • EM physicians, neuro emergencies

  • www.FERNE.org

  • Look for button on main page

  • 2001 ICEP Seizure Lecture


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