step by step management of seizures status epilepticus l.
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STEP BY STEP MANAGEMENT OF Seizures / STATUS EPILEPTICUS. Dr. D. Alvarez 2007. INITIAL PROCES. Call from the ED requesting bed for a patient with Seizures / Status Epilepticus.

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initial proces
INITIAL PROCES
  • Call from the ED requesting bed for a patient with Seizures / Status Epilepticus.
  • PICU Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED.
  • Information needed:
    • Base line patient’s: Previously healthy Or if any chronic condition.

- If previous diagnosed with Seizures > since ? age

      • Taking medications? Name, doses, Since when
        • time last dose ?, did tolerated or vomited?
      • Follow up by Neurology? Last visit
      • Previous studies (head CT, MRI)
      • Seizure control
      • Last Hospitalization?; intubation?; ED visit?
initial proces continue
INITIAL PROCES (continue)

B. Is this is first Episode?

Information of Current event/exacerbation:

  • Triggering factors, fever? Trauma?, medications? Or No obvious triggering /“Unprovoked”
  • Describe seizures,
    • Focal?, generalized
    • Onset: when awake ?, sleeping?, watching TV?
    • Duration
    • Interventions?
  • Treatments / management at home.
  • EMS, findings - treatments if applicable
ed events continue
ED Events… (continue)

4.- Review ED-Events

  • Condition on arrival > mental status Post ictal?
  • Airway maintainable? / intubated for airway protection (Fill up Mechanical Ventilation Order guidelines if applicable)
  • Studies / labs done (Start laboratory flow sheets record)
  • Radiological studies: Head CT, CxR
  • Lab reports
  • Treatments given: note, dose and time.

5.- Communicate with PICU Attending and inform on patient’s condition using the “30 sec assessment guideline”

6.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

physiological problems that need to be address assess
Physiological Problems that need to be Address / Assess.
  • Is Airway maintainable? / Secured (intubated)
  • Is Ventilation and oxygenation adequate
    • O2 Sats RA or % O2 needed
    • RR, deepness of respiratory effort, air entry.
    • ABG if patient is intubataed
  • Mental Status changes, any effect of medications given.
  • Focal neuro findings?
    • Pupilary reaction
slide7
3. Cardiovascular Assess
  • HR, Rhythm / Tachycardia
  • BP: Hypertension, hypotension, perfusion.

4. Hydration Status / Fluid-Electrolyte and ABB.

  • FS: hyperglycemia / hypoglycemia
  • Hyponatremia / hypernatremia
  • Metabolic acidosis
slide8

Assessment > If associated infection

Process.

  • By History
    • Fever
    • Respiratory symptoms
    • GI symptoms: vomiting / diarrhea
    • Travelinig
    • Contacts.
  • By Physical exam
  • By Studies:
    • CBC with diff (manual count) if clinically indicated
    • CxR, (if respiratory symptoms) looking for signs of aspiration.
    • Blood, U/A, CSF culture if indicated.
initial management 0 10min
Initial Management (0-10min)
  • ABC
    • OXYGEN should be given to all pat.actively seizing and/or alter mental status.
    • Open airway
    • Position patient
    • Assess if adequate ventilation
      • Observe for depth of respiration
      • Listen for air entry
  • Start IV
    • Check FS
    • Send for basic studies (CBC, Lytes)
initial management 10 20min
Initial Management (10-20min)
  • If hypoglycemia give
    • D25 > 2 ml/kg
  • Anticonvulsant Medication (see precalculated dose/drip protocole)
    • Lorazepan 0.1 mg/kg (2 mg/min)

OR

    • Diazepan 0.2 mg/kg (5mg/min)

OR

    • Diastat PR
      • 1-5 y ……….. 0.5 mg/kg
      • 6-10 y ……….. 0.3 mg/kg
      • > 12 y ……….. 0.2 mg/kg

Repeat ONCE if seizure does not stop within 5-10 min

management cont 20 40min
Management Cont.(20-40min)

Keep Patient on continues C-R monitoring with

  • frequent VS including BP and
  • monitoring A&B, keep airway open and continue given oxygen.

4. Fosphenytoin:

  • 20 mg/kg (slow infusion 150 mg/min, pat. On continuous monitoring)
  • If seizure persist, give additional 10 mg/kg

AND / OR

5. Phenobarbital

  • 20 mg/kg (50 mg/min)

POST BOLUS BLOOD LEVEL SHOULD BE DONE IN 1-2 HRS POST INFUSION.

management 60 min
Management > 60 min)

Refractory Status

  • Intubate
    • Premedicate with:
      • Midazolan:
        • 0.1 –0.3 mg/kg Load F/U by
        • 0.05-0.4 mg/kg/hr Maintenance

And / OR

      • Pentobarbital
        • 5-20 mg/kg load
        • 0.5-5 mg/kg/hr Maintenance
intubation process
Intubation Process
  • Call anesthesia (Emergency Beeper posted) if PICU attending not in house)
  • Calculate / Order / Prepare Medications
      • Rapid Sequence (RSI) INTUBATION MEDICATIONS
        • Midazolam: 0.05 to 0.1 mg/kg
        • Pentobarbital
          • 5-20 mg/kg load
          • 0.5-5 mg/kg/hr Maintenance Call Respiratory therapy
principles of mechanical ventilation support
Principles of Mechanical Ventilation Support
  • Order initial Mechanical Ventilatory setting according to guidelines after discussion with PICU attending
  • Continues drip (if indicated) with:
    • Midazolan: 0.05-0.4 mg/kg//min

OR

    • Pentobarbital: 0.5 – 5mg/kg/hr.
fluid therapy
Fluid Therapy

NPO until patient is awake and responsive

Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2)

A. Basic Requiremente

  • Wt base:
    • 100 ml/kg for the first 10 kg
    • 50 ml/kg for the next 10 kg
    • 20 ml/kg for the rest…. kg.
  • Per SA (m2) 1500 mL/M2

B. Add Insensitive extra loses given by:

  • Tachypnea
  • Fever

Check electrolytes, follow up Glucose

dilantin to be use only in case that phosphenitoin not available
Dilantin (To be use only in case that phosphenitoin not available)
  • Remember, this is consider a High Risk Medication, because serious side effect if not given correctly.
  • This are the recommendations
    • Dilute only in Normal Saline just before infusion. Not soluble in D5W and will precipitate.
    • 1 gm in 100 mL OR 500 mg in 50 mL of NS
    • Infusion rate at no faster than 50 mg/min by pump.
      • 5 mL/hr of either solution 1 gm in 100 ml or the 500 mg in 50 mL of NS solution
    • Monitor EKG and BP during infusion
    • Do not give Dilantin IM
    • The dose is 15 to 20 mg/kg
    • Adverse reactions: Hypotension, Bradicardia, phlegitis, purple glove syndrome.