emergency management of seizures deb funk, m.d., nremt-p medical director; albany medflight saratoga...

Emergency Management of Emergency Management of SeizuresSeizures

Deb Funk, M.D., NREMT-P

Medical Director;

Albany MedFLIGHT

Saratoga EMS

GoalsGoals

Review definitions, classifications and pathophysiology

Discuss several patient scenarios– Assessment– Management

Discuss current pharmacologic techniques for management of ongoing seizures

DefinitionsDefinitions

Seizure: episodic abnormal neurologic functioning caused by abnormally excessive activation of neurons

Epilepsy: a clinical condition characterized by recurrent seizures

status epilepticus: >30min seizure or >2 seizures w/o recovery

EpidemiologyEpidemiology

6-10% of US population will have at least 1 afebrile seizure during their lifetime

1-2% have recurrent seizures100,000 new cases in US annually

– Adult first time seizures represent 1% of all ED visits

incidence highest <20 and >60yrsMale > female

ClassificationClassification primary/secondary

– Primary do not have obvious source– Secondary occur as a result of many types of

injuries/illnesses

generalized/focal– generalized involves abnl neuron activity in both cerebral

hemispheres tonic/clonic, absence, myoclonic

– focal involve 1 hemisphere simple partial, complex partial, secondarily generalized

Generalized: Tonic-Clonic Generalized: Tonic-Clonic SeizureSeizure

most commonvague prodromal symptomstonic phase

– trunk flexion-->extension, eyes deviate up, mydriasis, vocalization

clonic phase– tonic contractions alternate with muscle atonia

Generalized: Tonic-Clonic Generalized: Tonic-Clonic cont’dcont’d

loss of consciousness and autonomic alterations during both phases

any focality noted during or after seizure may point to the origin

hypocarbia (resp alkalosis/lactic acidosis), transient hyperglycemia, CSF pleocytosis, elevated serum prolactin

post ictal phase– coma-->confusional state-->lethargy, myalgia,

headache

Pathophysiology of SeizuresPathophysiology of Seizures

in general not well understood neuronal recruitment is a common theory and has

been demonstrated in some studies– propagation of abnormal electrical impulse to adjacent

neurons along variable paths– the pathway involved usually determines the type of

seizure seen generalized sz: focus deep and midline, involving the RAS focal sz: more limited focus of activity/does not cross midline

Pathophysiology cont’dPathophysiology cont’d

typically self limited– bursts of electrical discharges from the focus

terminate reflex inhibition/neuronal exhaustion/alteration of

neurotransmitter balance.

Case 1Case 1

2 yr old previously healthy boy given Tylenol for tactile temp by Mom. Twenty min later had “shaking episode.”

What more do you need to know?What do you look for on exam?What is your assessment and plan?

Febrile Seizure: DefinitionsFebrile Seizure: Definitions

generalized seizure occurring during a sudden rise in temp in absence of intracranial infection or other defined etiology

Simple: single event lasting less than 15 min (90%)

Complex: exceed 15 min, occur more than once in 24hr period, or show focal motor manifestations (higher rate of epilepsy)

Febrile Seizure: StatisticsFebrile Seizure: Statistics

2-5% of childrenmost common pediatric seizure30% will have a single recurrence (1/2 of

these will have multiple)age of onset 6mos-5yrs (peak 18-24 mos)family history conveys 2-3 times the

general population risk2-9% develop afebrile seizures

Febrile Seizures: AssessmentFebrile Seizures: Assessment

History– PMH/AMPLE (immunization hx)– Recent illness– Details of event

Physical Exam– MS/ABC’s– Detailed neuro exam– Search for source of fever (in ED)

Febrile Seizure: managementFebrile Seizure: managementABCs and monitor VSCheck blood glucoseabort seizure if ongoing (benzodiazepine)

– IV/IM/PR administration

Cooling measuresTransport to appropriate hospital

Reference REMO Protocol P-10 Pediatric Seizures

Case 2Case 2

42 y/o WM reportedly had a seizure at a Phish concert. Friends think he takes Dilantin.

What more do you need to know?What do you look for on exam?What is your assessment and plan?

Epilepsy: ConsiderationsEpilepsy: Considerations

multiple different epilepsy syndromesbreakthrough vs noncomplianceprovoking factors

Epilepsy: statisticsEpilepsy: statistics

Affects 1.5-2.5 million people in US30-40% patients with epilepsy continue to

have breakthrough seizures despite appropriate medical management

Epilepsy: assessmentEpilepsy: assessment

History– determine:

intercurrent illness/trauma Sleep deprivation drug or etoh use drug drug interactions med compliance recent change in dosing regimen change in seizure pattern

Physical Exam– Evidence of injury– Detailed neuro exam

Epilepsy: managementEpilepsy: management

MS/ABC’sMonitor VS and check blood glucoseTreat any injuriesTransport to appropriate hospitalIV and ALS monitor:

– Multiple seizures– Single seizure without return to baseline state– Atypical seizure (type or pattern)

Reference REMO Protocols M-2 Active Seizures

Case 3Case 3

19 y/o female college student who “fell out” at a party. Witnesses describe generalized seizure activity. Confused/combative upon EMS arrival.

What more do you need to know?What do you look for on exam?What is your assessment and plan?

Differential ConsiderationsDifferential Considerations

Syncope Hyperventilation syndrome Prolonged breathholdling toxic and metabolic disorders

– ETOH abuse/withdrawal– hypoglycemia

other CNS event (TIA, migraine, narcolepsy) movement disorders (hemiballismus, tics) Psychiatric disorders (fugue state, panic attacks) Functional Disorders (pseudoseizure)

Characteristics of SeizureCharacteristics of Seizure

abrupt onsetbrief duration (90-120 sec)Altered mental status (except simple partial)purposeless activityunprovoked (except febrile)postictal state (except simple partial and

absence)

First Time Seizure: StatisticsFirst Time Seizure: Statistics

Rates of recurrence 23-71%Predictors of recurrence

– Etiology of seizure– EEG findings

Historical InformationHistorical Information

History vital in determining the appropriate ED approach– description of event– preceding aura– loss of bowel/bladder– duration of event– post ictal period– clinical context (precipitating factors?)

febrile illness head trauma sleep deprivation other stressor

– baseline seizure pattern

Initial AssessmentInitial Assessment

No longer seizing: recovery position, IV, glucose, medication history– preventative medications?

Is seizing still:– Airway assessment (npa, suction, ETT prn)– protect patient from self injury – pulseox, monitor, IV access, blood glucose

(hypoglycemia is the most common metabolic cause of sz, but can also be a result of prolonged sz…needs to be treated aggressively either way)

– abortive therapies

Detailed Physical ExamDetailed Physical Exam Done after cessation of seizure activity assess for injuries

– posterior shoulder dislocation common Temperature assessment Bedside glucose determination Cardiac Monitor Assess for presence of systemic disease, toxic exposure,

infection, focal neurologic event serial neurologic exams

– Todd’s paralysis: focal deficit following a seizure lasting less than 48 hours

Typical Physical Exam Typical Physical Exam FindingsFindings

HTN, tachycardia, tachypnea during seizure activity

incontinence, vomiting, tongue bitinglow grade temp common after generalized

seizure

First Time Seizure: First Time Seizure: ManagementManagement

MS/ABC’s Monitor VS and check blood glucose IV access (draw labs) Cardiac monitor Treat any injuries Transport to appropriate hospital No benzodiazepines unless seizure recurs or

continues

Reference REMO Protocols M-2 Active Seizures

Case 4Case 4

6 y/o WF presents s/p “seizure.” During transport EMS witnesses a generalized tonic-clonic event.

What more do you need to know?What do you look for on exam?What is your assessment and plan?

Status Epilepticus: Status Epilepticus: ConsiderationsConsiderations

continuous clinical or electrical seizure activity or repetitive seizures with incomplete neurological recovery for >30 min

Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min)

impending SE if >3 tonic-clonic seizures within 24hrs

Generalized or Partial

Status Epilepticus: Status Epilepticus: ConsiderationsConsiderations

Generalized convulsive activity results in: hypoxia hyperpyrexia BP instability and cerebral dysautoregulation respiratory and metabolic acidosis hyperazotemia/hypokalemia/hyponatremia hyperglycemia followed by hypoglycemia marked elevations of prolactin, glucagon, growth

hormone and corticotropin rhabdomyolysis may produce myoglobinuria and renal

failure

Status Epilepticus: StatisticsStatus Epilepticus: Statistics

195,000 episodes in US annually 42,000 deaths annually in US 50% due to acute CNS insults (anoxia, TBI, CVA,

neoplasm, infection)– peds: fever/infection– elderly: cerebrovascular disease

20% in epileptic patients during med adjustment or due to noncompliance

30% undetermined etiology

Status Epilepticus: Status Epilepticus: AssessmentAssessment

HPI/AMPLEDetailed exam and history taking done once

seizure has been stopped and patient has been stabilized

Status Epilepticus: Status Epilepticus: ManagementManagement

Rapid Seizure control– Patients do better when seizure treated by EMS

Step 1:– ABC’s

NPA, OPA, ETT If RSI needed use only short acting paralytics

– blood glucose– Cardiac Monitor– IV access– HPI/PE

Further specific treatment based upon circumstance

Status Epilepticus: Status Epilepticus: ManagementManagement

Step 2: 1st line drugsStep 3: 2nd line drugsStep 4: 3rd line drugs

The longer the seizure continues;– The more difficult it is to stop – The more likely permanent CNS injury will

occur

Medication OptionsMedication Options

First line– diazepam (Valium) IV/ET/IO/PR– lorazepam (Ativan)IV/IN– midazolam (Versed)IV/IM/IN

Second line– phenytoin/fosphenytoin – phenobarbital

Lastly induction of anesthesia w. cont. EEG– Infusions of midazolam, diprivan, valproic acid,

pentobarbital– Inhaled isoflurane

Rectal Route of Rectal Route of AdministrationAdministration

• Surface area=200-400 cm2 (1/10,000 absorptive area of small intestine)• Highly vascularized• Passive diffusion

Rates of Diazepam Absorption by Various

Routes

Moolenaar F. Int J Pharma. 1980.

First Line AnticonvulsantsFirst Line AnticonvulsantsDRUG ADULT DOSE PEDS DOSE OTHER INFO

Diazepam .2mg/kg up to 20mg at 2mg/min

.2-.5mg/kg IV/IO or .5-1.0mg/kg PR up to 20mg

CNS/CV/Resp depression

Onset 1min

Lasts 20-30min (longer PR)

Lorazepam .1mg/kg IV max 10mg at 2mg/min

**Intranasal use promising

.05-.1mg/kg IV

**Intranasal use promising

CNS/CV/Resp depression

Onset 2min

Lasts >12hrs

Midazolam .1mg/kg IV up to 10mg at 1mg/min or .2mg/kg IM

**Intranasal use promising

.15mg/kg IV

.2mg/kg IM

**Intranasal use promising

Less depression

Onset 1min

Short duration

Second Line AnticonvulsantsSecond Line AnticonvulsantsDRUG ADULT DOSE PEDS DOSE OTHER INFO

Phenytoin 20mg/kg IV at 50mg/min

20mg/kg IV at 1mg/kg/min

Hypotension, arrhythmias Onset 10-30min

Long acting

Fosphenytoin 15-20PE/kg IV at 150mg/min or 20PE/kg IM

10-20PE/kg IV at 3mg/kg/min or 20PE/kg IM

Can be given faster

Expensive

Same times once given

Phenobarbital 10-20mg/kg IV at 30mg/min or 20mg/kg IM

May rpt to 40mg/kg total

Same as adult Resp/CV depression

Rapid onset, long acting

Third Line AnticonvulsantsThird Line AnticonvulsantsDRUG ADULT PEDS OTHERMidazolam .15mg/kg IVthen

1mcg/kg/min

up 1mcg/kg/min q15

As adult CNS/Resp/CV depression

Propofol 1-3mg/kg IV then 2-10mg/kg/h

Caution in <12yrs (reports of met. Acidosis)

CNS/Resp/CV depression

Valproic Acid 20-40mg/kg IV over 5min then 5mg/kg/h

As adult hypotension

Pentobarbital 5mg/kg IV at 25mg/min

As adult Titr.to EEG

ETT/CV support

Isoflurane Via gen’l ETT anesthesia

As adult Titr. to EEG

ETT/CV support

ConclusionsConclusions

Seizures are common presenting problems to EMS.

Status epilepticus must be treated rapidly to avoid significant morbidity.

Familiarity with protocols and medication options is crucial.

Questions?Questions?

ReferencesReferences

American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg Med. May 1997;29:706-724.

ACEP, AAN, AANS, ASN: Practice parameter: Neuroimaging in the emergency patient presenting with seizure (summary statement). Ann Emerg Med. 1996;28:114-118.

Smith, BJ. Treatment of Status epilepticus. Neurologic Clinics. May 2001;19:2

Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emergency Medicine Clinics of North America. Feb 1999;17:1

References cont’dReferences cont’d Goetz. Epileptic Seizures. Textbook of Clinical Neurology, 1st

ed. WB Saunders 1999. pp1062-1079 Pollack CV. Seizures. Rosen’s Emergency Medicine: Concepts

and Clinical Practice, 5th Ed. Mosby 2002. Pp145-149 Hanhan UA, Fiallos MR, Orlowski JP. Status Epilepticus.

Pediatric Clinics of North America. Jun 2001;48:3 Lahat E, Goldman M, Barr J, et al. Comparison of intranasal

midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. BMJ. July 200;321:83-86

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children. Neurology. Sept 2000;55:5