43
SHAKE and BAKE SAMIR SHAHANI PGY-3

Seizures Dr. Samir Shahani

Embed Size (px)

DESCRIPTION

Dr. Samir Shahani's Senior Grand Rounds Presentation on evidenced based approach to seizures.

Citation preview

Page 1: Seizures   Dr. Samir Shahani

SHAKEand BAKE

SAMIR SHAHANI PGY-3

Page 2: Seizures   Dr. Samir Shahani
Page 3: Seizures   Dr. Samir Shahani

Time is Brain

Page 4: Seizures   Dr. Samir Shahani

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%

Page 5: Seizures   Dr. Samir Shahani

Differential

• Syncope• Metabolic Conditions• Migraine• Vascular Conditions• Sleep Disorders• Paroxysmal Movement Disorders• Psychological Disorders• Infection• Trauma• Malignancy

Page 6: Seizures   Dr. Samir Shahani

Seizure Classification

• Provoked Seizure– Electrolyte Abnormalities–Withdrawal vs Toxic Ingestion– Infection– CNS Mass– Pregnancy– Trauma

• Unprovoked Seizures

Page 7: Seizures   Dr. Samir Shahani

The Basics

• Generalized• Focal (Partial)• Focal with Secondary Generalization• Status Epilepticus

Page 8: Seizures   Dr. Samir Shahani

Status Epilepticus Definition

• Epidemiologic• ≥ 30 minutes

• New Definition• ≥ 5 minutes• 2 or more seizures without recovery of

consciousness

• Pathological• Failure of inhibitory pathways (GABA)

Page 9: Seizures   Dr. Samir Shahani

The Assessment

Page 10: Seizures   Dr. Samir Shahani

History• First Time Seizure vs Recurrence?• Describe Event–Movement– Eye Deviation– Duration

• Medications• Social History• Review of Systems

Page 11: Seizures   Dr. Samir Shahani

Physical

• Vitals• General• Eyes• Neck• Neurological

Page 12: Seizures   Dr. Samir Shahani

Labs• Glucose• Electrolytes• Pregnancy Test• Toxicology Studies• CSF Studies• Lactate• Prolactin• Antiepilectic Drug (AED) Levels• Blood Gas

Page 13: Seizures   Dr. Samir Shahani

Imaging and Diagnostic Studies

• CT Head w/o Contrast• MRI w/o Contrast• EEG

Page 14: Seizures   Dr. Samir Shahani

Management

Page 15: Seizures   Dr. Samir Shahani

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

Page 16: Seizures   Dr. Samir Shahani

New Onset Seizures

Should I Start AED?– Recurrence Rate < 30-50%– Consider Starting If:• Structural lesion on CT• Focal Deficit• Positive EEG

Page 17: Seizures   Dr. Samir Shahani

Abortive Therapies

Page 18: Seizures   Dr. Samir Shahani

Benzodiazpines

• Diazepam– Quickest Onset– Dose: 10 mg PR, IM

• Midazolam– Fast Onset– Dose: • 2-4 mg IV, IM• 5 mg per nostril IN

Page 19: Seizures   Dr. Samir Shahani

Benzodiazpines

• Lorazepam– Longer Duration of Action– Can be used alone– Dose: 2-4 mg IV, IM

Page 20: Seizures   Dr. Samir Shahani

Phenytoin vs Fosphenytoin

• No studies have compared efficacy• Phenytoin is generally cheaper• Fosphenytoin is well tolerated• Fosphenytoin reaches the Brain

Faster

Page 21: Seizures   Dr. Samir Shahani

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

Page 22: Seizures   Dr. Samir Shahani

Phenobarbital

• 20 mg/kg over 20 minutes• Risk of Apnea and Hypotension• Get Ready To Intubate

Page 23: Seizures   Dr. Samir Shahani

Other Agents

• Valproic Acid– Avoid in Hepatic Disease– Teratogenic– Dose: 20 mg/kg

• Levitracetam– Extremely Safe– Dose: 20 mg/kg

Page 24: Seizures   Dr. Samir Shahani

“The Longer A seizure Persists, the more refractory to treatment it will become”

Wheless, 1996

Page 25: Seizures   Dr. Samir Shahani

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

Page 26: Seizures   Dr. Samir Shahani
Page 27: Seizures   Dr. Samir Shahani

Seizures Simplified

Page 28: Seizures   Dr. Samir Shahani

Seizures Simplified

Stabilize the Patient

Page 29: Seizures   Dr. Samir Shahani

Seizures Simplified

Finger Stick Blood Glucose

Page 30: Seizures   Dr. Samir Shahani

Seizures Simplified

Time Seizure Monitor Vital Signs

Page 31: Seizures   Dr. Samir Shahani

Seizures Simplified

Attempt IV AccessCollect Blood

Page 32: Seizures   Dr. Samir Shahani

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

Page 33: Seizures   Dr. Samir Shahani

Seizures Simplified

IV Access?

Yes. IV Lorazepam x 2 q 3 minand then Fosphenytoin

No. PR DZP, IN MDZ, IM MDZ, IO

Page 34: Seizures   Dr. Samir Shahani

Seizures Simplified

Seizure Continues?

Yes. Levetiracetam, Valproic Acid, Phenobarbital, Versed,

PropofolNo. Continue Medical CareMaybe. Bedside EEG

Page 35: Seizures   Dr. Samir Shahani

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)

Page 36: Seizures   Dr. Samir Shahani

Evidence Based Medicine

Page 37: Seizures   Dr. Samir Shahani

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

Page 38: Seizures   Dr. Samir Shahani

2014 ACEP Clinical Policy

• First Time Seizure, Start AEDs?– Level C: No.

• Admit First Time Seizures?– Level C: No.

Page 39: Seizures   Dr. Samir Shahani

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

Page 40: Seizures   Dr. Samir Shahani

Take Home

• Time is Morbidity and Success• Check a Glucose• Think Secondary Causes• Simplify Seizures: Have a Plan

Page 41: Seizures   Dr. Samir Shahani

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?

Page 42: Seizures   Dr. Samir Shahani

Thanks and ?’s

Special Thanks Dr. Williams

Page 43: Seizures   Dr. Samir Shahani

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.