1 / 74

Edward P. Sloan, MD, MPH, FACEP

The ED Treatment of Seizure and SE Patients: What the 2004 ACEP Seizure Clinical Policy Doesn’t Tell You. Edward P. Sloan, MD, MPH, FACEP. 1. Edward Sloan, MD, MPH, FACEP. Professor & Research Development Director Department of Emergency Medicine, University of Illinois at Chicago

liko
Download Presentation

Edward P. Sloan, MD, MPH, FACEP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. The ED Treatment of Seizure and SE Patients:What the 2004 ACEP Seizure Clinical Policy Doesn’t Tell You Edward P. Sloan, MD, MPH, FACEP 1

  2. Edward Sloan, MD, MPH, FACEP Professor & Research Development Director Department of Emergency Medicine, University of Illinois at Chicago Chicago, IL (edsloan@uic.edu)

  3. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL Edward P. Sloan, MD, MPH, FACEP 3

  4. Global Objectives • Learn more about seizures • Increase awareness of Rx options • Enhance our ED management • Improve patient care & outcomes • Maximize staff & patient satisfaction

  5. Session Objectives • Discuss what the policy doesn’t tell us • Provide seizure and SE concepts • Examine epidemiology, diagnosis, ED Rx • Generate a common perspective • Highlight areas for improvement • Outline opportunities • Develop a plan

  6. Clinical History • 24 yo female • EMS to ED • Generalized seizure at home • CFD: IV diazepam, resolved • Hx seizure since childhood • On Depakote • No recent BHT • No recent illness

  7. ED Presentation • Post-ictal in ED • Non-focal neurological exam • No evidence of trauma or toxicity • Appropriate, verbal, answers questions • Has recurrent generalized seizure • Prolonged duration (>5 min) • Is this patient an outlier? • What is his optimal management?

  8. What the 2004 ACEP Seizure Clinical PolicyDoesn’t Tell Us Edward P. Sloan, MD, MPH, FACEP 9

  9. Important Sz/SE Info • What is the pathology that we treat? • How do we simply classify Sz/SE? • What is an acceptable SE protocol? • What is the time frame for Rx?

  10. Important Sz/SE Info • What therapies can be used? • What therapies should be used? • Based on what evidence and consensus should these decisions be made? • Why? In which patients?

  11. Epidemiology & Pathophysiology Edward P. Sloan, MD, MPH, FACEP 12

  12. Seizure Epidemiology • Epilepsy in 1/150 people • For each epilepsy pt, 1 ED visit every 4 years • 1-2% of all ED visits • Toxic/metabolic, febrile, non-compliance, trauma

  13. Seizure Mechanism • Sz = abnormal neuronal discharge with recruitment of otherwise normal neurons • Loss of GABA inhibition

  14. Status Epilepticus • Seizure > 5- 10 minutes • Two seizures without a lucid interval • Assumes ongoing seizure activity during time of diminished responsiveness

  15. SE Pathophysiology • Early compensation meets increased CNS metabolic needs (SBP, CBF ↑↑) • Failure at 40-60 minutes, (SBP, CBF ↓↓) • CNS tissue necrosis, adverse sequelae

  16. SE Pathophysiology • Glutamate toxic mediator • CNS necrosis even if systemic complications fully mitigated • HTN, fever, rhabdomyolysis, hypercarbia, hypoxia, infection

  17. AMS in Seizures/SE • Mental status should improve by 20-40 minutes • If pt remains comatose, consider subtle SE & EEG • Up to 20% of comatose pts in are in subtle SE

  18. Status EpilepticusSE Epidemiology: • Risk of SE: greatest at age extremes (pediatric and geriatric populations) • SE: occurs in setting of new onset sz, acute insult, or chronic epilepsy • 150,000 cases per year

  19. Status EpilepticusSystemic SE Effects: • Hypertension (early) • Hypotension (later) • 49% Temp > 100.5 F° • Lactic acidosis (pH < 7.00) • Hypercarbia (increased pCO2)

  20. Status EpilepticusOngoing SE Effects: • Over 40-60 min, loss of metabolic compensation • With ongoing SE, systemic BP & CBF drop

  21. Status EpilepticusSE Mortality: • SE mortality > 30% when sz longer than 60 minutes • Underlying sz etiology contributes to mortality

  22. New-Onset: Sz Recurrence • 51% seizure recurrence risk • 75% of recurrent seizures occur within 2 years of first sz • Within 24 hours of ED visit: a small % will seize (1%) • Partial sz, CNS abn inc risk

  23. Seizure and SE Patient Classification Edward P. Sloan, MD, MPH, FACEP 24

  24. Seizure Classification • Generalized: both cerebral hemispheres • Partial: one cerebral hemisphere (localized)

  25. Generalized Seizures • Convulsive: tonic-clonic • Non-convulsive: absence

  26. Generalized Seizures • Primary generalized: starts as tonic-clonic sz • Secondarily generalized: tonic-clonic sz from a non-convulsive partial sz, ie aura (common)

  27. Partial Seizures • Simple partial: no impaired consciousness • Complex partial: impaired consciousness

  28. Specific Seizure Types • Absence: Petit mal • Partial: Jacksonian, focal motor • Complex partial: temporal lobe, psychomotor

  29. SE Classification • GCSE: Generalized convulsive SE Tonic-clonic motor activity • Non-GCSE

  30. 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

  31. Subtle SE • Severe insult, ie hypoxic • Comatose • Limited motor activity • Mortality exceeds 50% • Stop the seizure • EEG confirmation

  32. Refractory SE • No response to first-line drugs (Benzos, phenytoins) • Severe CNS pathology • 6-9% of all SE cases • Overlap with subtle SE Dx??

  33. Seizure and SE Patient Management Edward P. Sloan, MD, MPH, FACEP 34

  34. Seizure/SE Pharmacotherapy • Benzodiazepines • Phenytoins • Barbiturates • Other agents • valproate • propofol • lidocaine

  35. ED SE Treatment • 0-30 min: ABCs, benzos • 30-45 min: Phenytoins • 45-75 min: Phenobarb/valproate • 75-90 min: Propofol/midazolam • 90-150 min: CT, EEG, ICU/OR

  36. ED AED Use: Concepts • Most drugs are at least 80% effective in Rx seizures, SE • Utilize a protocol • Have AEDs available in ED • Maximize infusion rate in SE • Provide full mg/kg doses

  37. ED ManagementAED loading: • Repeated seizures, high-risk population, significant SE risk • No need to determine level in ED after loading • Oral loading in low risk pts

  38. PharmacotherapyBenzodiazepines: • GABA inhibition • Diazepam: short acting, limited AMS and protection (intubation more common) • Lorazepam: prolonged AMS and protection • Pediatric sz: IV lorazepam limits respiratory compromise

  39. PharmacotherapyRectal Diazepam: • Diazepam rectal gel pre-packaged for rapid use • Dose 0.5 mg/kg, less respiratory depression seen than with IV use

  40. PharmacotherapyPhenytoin: • Stabilize memb Na+ channels, regulate Ca+ + channels • For Generalized sz, and SE • Constant infusion over IVP • Use pump to prevent comp • Therapeutic at 10-20 µg/mL

  41. PharmacotherapyOral Phenytoin: • 18mg/kg oral load • 64% reach 10mg/mL levels by 8 hrs (therapeutic) • Delayed absorption due to large loading, or drug prep

  42. PharmacotherapyFosphenytoin: • Pro-drug, dose same as pht • 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

  43. PharmacotherapyFosphenytoin: • Cost-effective in 5 settings • Rapid infusion in SE • High-risk IV access • No IV access (IM) • No cardiac monitoring (IM) • Poor patient compliance

  44. PharmacotherapyIV Phenobarbital: • GABA-inhib, effective SE Rx • Infuse up to 50 mg/min • 20-30 mg/kg, 10 mg/kg doses • Therapeutic > 40 µg/mL • Respiratory depression • Hypotension

  45. PharmacotherapyIV Valproate: • Likely GABA mechanism • Useful in peds, possibly SE • Rate up to 300 mg/min • 25-30 mg/kg, 3-6 mg/kg/min • Therapeutic > 100 µg/mL

  46. PharmacotherapyLidocaine: • Third-line, stabilizes membrane Na + /K + pump • Decreased neuron excitability, refractory GCSE • 3 mg/kg

  47. PharmacotherapyIV Propofol Infusion: • Likely GABA mechanism • Provides burst suppression • 2 mg/kg loading dose • Hypotension, acidosis, hypoventilation • Rapid onset, easily reversed

  48. PharmacotherapyIV Midazolam Infusion: • GABA mechanism • Equal to diazepam infusion • Greater breakthru sz rates • Less hypotension • Vs. propofol, pentobarb

  49. PharmacotherapyIV Pentobarbital: • Likely GABA mechanism • Provides burst suppression • 5 mg/kg loading dose • 25 mg/kg infusion rate • ICU monitoring required

More Related