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Dr. Samir Shahani's Senior Grand Rounds Presentation on evidenced based approach to seizures.
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SHAKEand BAKE
SAMIR SHAHANI PGY-3
Time is Brain
Why should you Care?
- Prevalence: 1 out of 100 people- 1-2% of all ED visits- 3 million people in US
- 200,000 new cases each year
- Overall Mortality of Status is 20%
Differential
• Syncope• Metabolic Conditions• Migraine• Vascular Conditions• Sleep Disorders• Paroxysmal Movement Disorders• Psychological Disorders• Infection• Trauma• Malignancy
Seizure Classification
• Provoked Seizure– Electrolyte Abnormalities–Withdrawal vs Toxic Ingestion– Infection– CNS Mass– Pregnancy– Trauma
• Unprovoked Seizures
The Basics
• Generalized• Focal (Partial)• Focal with Secondary Generalization• Status Epilepticus
Status Epilepticus Definition
• Epidemiologic• ≥ 30 minutes
• New Definition• ≥ 5 minutes• 2 or more seizures without recovery of
consciousness
• Pathological• Failure of inhibitory pathways (GABA)
The Assessment
History• First Time Seizure vs Recurrence?• Describe Event–Movement– Eye Deviation– Duration
• Medications• Social History• Review of Systems
Physical
• Vitals• General• Eyes• Neck• Neurological
Labs• Glucose• Electrolytes• Pregnancy Test• Toxicology Studies• CSF Studies• Lactate• Prolactin• Antiepilectic Drug (AED) Levels• Blood Gas
Imaging and Diagnostic Studies
• CT Head w/o Contrast• MRI w/o Contrast• EEG
Management
New Onset Seizures
CT Head Without Contrast– Easy to obtain– First Time Seizures in setting of Etoh or
Etoh Withdrawal: 6.2% had significant finding
Lumbar Puncture– Fever, Immunocompromised, AMS, severe
HA
New Onset Seizures
Should I Start AED?– Recurrence Rate < 30-50%– Consider Starting If:• Structural lesion on CT• Focal Deficit• Positive EEG
Abortive Therapies
Benzodiazpines
• Diazepam– Quickest Onset– Dose: 10 mg PR, IM
• Midazolam– Fast Onset– Dose: • 2-4 mg IV, IM• 5 mg per nostril IN
Benzodiazpines
• Lorazepam– Longer Duration of Action– Can be used alone– Dose: 2-4 mg IV, IM
Phenytoin vs Fosphenytoin
• No studies have compared efficacy• Phenytoin is generally cheaper• Fosphenytoin is well tolerated• Fosphenytoin reaches the Brain
Faster
Fosphenytoin
• Does not Contain Propylene Glycol• Can be Given Faster than Phenytoin– Phenytoin 50 mg/min– Fosphenytoin 150 PE/min
• Dose: 20 mg/kg ± 10 mg/kg
Phenobarbital
• 20 mg/kg over 20 minutes• Risk of Apnea and Hypotension• Get Ready To Intubate
Other Agents
• Valproic Acid– Avoid in Hepatic Disease– Teratogenic– Dose: 20 mg/kg
• Levitracetam– Extremely Safe– Dose: 20 mg/kg
“The Longer A seizure Persists, the more refractory to treatment it will become”
Wheless, 1996
Time To Treatment = Response
Duration (Min) All Seizures Stop
7.3 ± 2.57 6/6
16.2 ± 5.06 3/6
38.7 ± 15.5 1/6
127.0 ± 10.3 1/6
Wheless, 1996
*Data Using Diazepam
Seizures Simplified
Seizures Simplified
Stabilize the Patient
Seizures Simplified
Finger Stick Blood Glucose
Seizures Simplified
Time Seizure Monitor Vital Signs
Seizures Simplified
Attempt IV AccessCollect Blood
Seizures Simplified
If Glucose < 60 mg/d
Adults: 100 mg Thiamine, 1 amp D50Children: >2 yrs 2ml/kg D25W
< 2 yrs 4ml/kg D12.5W
Seizures Simplified
IV Access?
Yes. IV Lorazepam x 2 q 3 minand then Fosphenytoin
No. PR DZP, IN MDZ, IM MDZ, IO
Seizures Simplified
Seizure Continues?
Yes. Levetiracetam, Valproic Acid, Phenobarbital, Versed,
PropofolNo. Continue Medical CareMaybe. Bedside EEG
Refractory Status Epilepticus
Claassen J et al, Epilepsia, 2002; 43: 146-153
Midazolam (N=54)
Propofol (N = 33)
Pentobarbital (N=106)
Acute Treatment Failure
20% (11) 27% (9) 8% (8)
Seizure Recurrence
51% (23) 15% (2) 12 % (11)
Ultimate Treatment Failure
21% (10) 20% (4) 3% (3)
Hypotension- Vasopressors Needed
30% (14) 42% (10) 77% (79)
Evidence Based Medicine
2004 ACEP Clinical Policy
• What Lab Tests?– Level B: Glucose, Sodium, Calcium,
Consider LP, Pregnancy Test
• Should you get CT on first time seizure?– Level B: Yes
2014 ACEP Clinical Policy
• First Time Seizure, Start AEDs?– Level C: No.
• Admit First Time Seizures?– Level C: No.
2014 ACEP Clinical Policy
• Known Seizure Disorder, Does Route of Loading affect recurrence?– Level C: No.
• Status Epilepticus, Benzo’s Did not work?– Level A: Try something else– Level B: Fosphenytoin, Phenytoin, Valproate– Level C: Levetiracetam, Propofol, Barbituates
Take Home
• Time is Morbidity and Success• Check a Glucose• Think Secondary Causes• Simplify Seizures: Have a Plan
Status Algorithm Seizure > 5 min
ABC’sNo IV
AccessIM/IN Midazolam, IM/PR Diazepam
or IO
Yes IV Access
Lorazepam 2-4mg IV q 3
min
Fosphpenytoin20-30 mg/kg IV
Sz Continues?
Phenobarbital 20-30 mg/kgIV or
Valproic Acid 20 mg/kg
InfusionPropofolVersed
Pentobarbital
Sz Continues?
Thanks and ?’s
Special Thanks Dr. Williams
Resources• Dodson WE et al, JAMA, 1993; 270: 854-859.• Lowenstein DH et al, Epilepsia; 1999; 40: 120-122.• Corey LA et al, Neurology, 1998; 50: 558-560.• Hauser WA, Hesdorffer DC. Epilepsy: frequency, causes, and
consequences. New York: Demos Publications; 1990.• EarnestMP,Etal.Neurology 1988; 38: 1561-5• Prasad K, Al-Roomi K, Krishnan PR, et al. Anticonvulsant therapy for
status epilepticus.Cochrane Database Syst. Rev. 2005, Issue 4. Art No.:CD003723. DOI: 10.1002/14651858.CD003723.pub2.
• American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. May 2004;43(5):605-25
• Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. Feb 2002;43(2):146-53.