the management of seizures and se in the emergency department

The Management of Seizures and SE in the

Emergency Department

Associate Professor &Research Development Director

Department of Emergency Medicine, University of Illinois at Chicago

Chicago, IL

([email protected])

Edward Sloan, MD, MPH, FACEP

Edward Sloan, MD, MPH

Global ObjectivesGlobal Objectives

Learn more about seizures Increase awareness of Rx options Enhance our ED management Improve patient care & outcomes Maximize staff & patient satisfaction Be prepared for the EM board exam


Session ObjectivesSession Objectives

Provide seizure and SE overview Summarize what Rx options exist Discuss specific sub-groups Outline ED Rx strategies


Sz Epidemiology:Epilepsy seen in 1/150

peopleFor each epilepsy pt, 1 ED

visit every 4 years1-2% of all ED visitsSignificant costs


Seizure Mechanism: Sz = abnormal neuronal

discharge with recruitment of otherwise normal neurons

Loss of GABA inhibition


Pathophysiology: Glutamate toxic mediator

Necrosis occurs even if systemic problems are treated (HTN, fever, rhabdomyolysis, resp acidosis, hypoxia)


Pathophysiology: Early compensation for

increased CNS metabolic needs

Decompensation at 40-60 minutes, associated with tissue necrosis


Seizure Classification:Generalized: both cerebral

hemispheres

Partial: one cerebral hemisphere


Generalized Seizures :Convulsive: tonic-clonic

Non-convulsive: absence


Generalized Seizures :Primary generalized: starts

as tonic-clonic seizureSecondarily generalized:

tonic-clonic seizure occurs as a consequence of a non-convulsive seizure


Partial Seizures :Simple partial: no impaired

consciousness

Complex partial: impaired consciousness


Specific Seizure Types :Absence: Petit mal Partial: Jacksonian, focal

motorComplex partial: temporal

lobe, psychomotor


Status Epilepticus:Sz > 5- 10 minutes = SE

Two sz without a lucid interval = SE (Assumes ongoing sz during coma)


SE Epidemiology: Risk of SE greatest at extremes of

age: pediatric and geriatric populations

SE: occurs in setting of acute insult, chronic epilepsy, or new onset seizure

150,000 cases per year


SE Classification:GCSE: Generalized

convulsive SE, with tonic-clonic motor activity

Non-GCSE


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


AMS in Seizures:Mental status should

improve by 20-40 minutes If pt comatose, then subtle

SE is possible: EEGUp to 20% of pts with

coma still are in SE


Ongoing SE Effects:Over 40-60 min, loss of

metabolic compensation

With ongoing SE, systemic BP & CBF drop


SE Mortality:SE mortality > 30% when

sz longer than 60 minutes

Underlying sz etiology contributes to mortality


Subtle SE:Mortality exceeds 50%Often after hypoxic insultComaLimited motor activityStop the sz, EEG confirm


General ED Management:ABCsGlucose, narcan, thiamineRapid sequential use of

AEDsDirected evaluation


Lab Evaluation:Key lab abnormality:

hypoglycemia, in up to 2%

Directed labs, including anti-epileptic drug levels


Lumbar Puncture: Fever and CSF pleocytosis

can occur in SE without meningitis

Use clinical criteria to determine LP need

AMS, immunocompromise, meningismus


Neuroimaging with CT:CT useful with focal sz,

change in sz type or frequency, co-morbidity

Req’d in new-onset szNon-contrast unless mass

lesion suspected


Neuroimaging with MRI:Useful with refractory sz Complements plain CTCan be done as outpt


EEG Monitoring:EEG to rule out subtle SEProlonged coma, RSI,

induced coma with propofol, pentobarbital

Obtain EEG in 120 minutesTwo-lead EEG in ED


AED loading:Repeated seizures, high-

risk population, significant SE risk

No need to determine level in ED after loading

Oral loading in low risk pts


Hospital Admission:Repeated sz, high-risk pt,

significant SE riskEsp if no AED loading New-onset seizure:

admission is preferred (complete w/u, observe)


New-Onset Sz: Recurrent Sz 51% recurrence risk 75% of recurrent sz occur

within 2 years of first sz Only a small % of pts will seize

within 24 h Partial sz, CNS abn inc risk


ED Discharge:Follow-up & EEG needed,

esp if no AED prescribed

Driving documentation is critical. Know state law.


Pharmacotherapy of Seizures Benzodiazepines Phenytoins Barbiturates Other agents

valproate propofol


General AED Concepts:Most drugs are at least 80%

effective in Rx seizures, SEHave AEDs available in EDMaximize infusion rate in SEUse full mg/kg doses


Benzodiazepines: GABA drug Diazepam: short acting, limited

AMS and protection Lorazepam: prolonged AMS and

protection Pediatric sz: IV lorazepam limits

respiratory compromise


Rectal Diazepam:Diazepam rectal gel pre-

packaged for rapid use

Dose 0.5 mg/kg, less respiratory depression seen than with IV use


Phenytoin:Phenytoin: Na+ channel RxLoad at 18 mg/kg, 1.5 doses Infuse at 50 mg/min maxUse pump to prevent comp Level 10-20 µg/mL


Fosphenytoin:Fos: pro-drug, dose same Infuse at 150 mg/min in SECan be given IM up to 20ccLevel 10-20 µg/mL Delayed level: 2h IV, 4 h IM


IV Phenobarbital:GABA-like, effective sz RxLimited availability Infuse up to 50 mg/min20-30 mg/kg, 10 mg/kg dosesLevel > 40 µg/mL


IV Valproate:Likely GABA mechanismUseful in peds, possibly SERate up to 300 mg/min25-30 mg/kg, 3-6 mg/kg/minLevel > 100 µg/mL


Refractory SE: SE refractory to benzos, phts,

phenobarb, valproate Propofol, pentobarb: useful third

line agents Midazolam infusion also useful Respiratory depression, BP Must control airway, get EEG


IV Propofol:Likely GABA mechanismProvides burst suppression2 mg/kg loading doseHypotension, resp

depression, acidosisEasily reversed


IV Pentobarbital:Likely GABA mechanismProvides burst suppression5 mg/kg loading dose25 mg/kg infusion rate ICU monitoring required


ED Treatment Protocol: Have AEDs easily available Rapid sequential AED use Maximize infusion rate Maximize mg/kg dosing Benzos, phenytoins, phenobarbital,

valproate


No IV Access: PR diazepam IM midazolam IM fosphenytoin Buccal, intranasal midazolam No IM phenytoin/phenobarbital


Special Populations Drug and alcohol-related seizures Acute CVA Post-traumatic Pregnancy Pediatrics Elderly Psychogenic seizures


Drug-related Sz:Stimulants, anti-depressants,

theophylline and cocaine commonly can cause sz

Most sz treated with benzos Phenytoin less useful


Drug-related Sz Rx: INH: Blocks GABA production

Vit B6, pyridoxine 5 gr IVP x 6, match ingestion gr

Theophylline: eliminate with hemodialysis, hemoperfusion

Tricyclics, cocaine: benzos,?? utility of other drugs


EtOH-related Seizures:Occur 12 hrs p last drinkLorazepam optimal Rx for szLorazepam in DTs and sz

preventionPhenytoin ?? sz flurries, SE


Seizures in Acute CVA:Seizures can occur in strokeConsider prophylaxis with

elderly, large hemorrhage, anterior CVA location


Post-traumatic Seizures:High-risk populations exist Early prophylaxis stops

early sz, not late sz onsetPhenytoins, valproate


Seizures in Pregnancy: Seizures related to changing

AED levels and eclampsia Benzos may be useful initially Magnesium 4-6 g load, 1-2 g/hr Respiratory depression, BP


Pediatric Seizures: Peds sz, SE in kids 0-3 yrs Common ED problem 80% are febrile sz CNS abnormalities: afebrile sz Cocaine, hyponatremia, meningitis Outcome good, CNS plastic


Febrile Seizures:6 months to 5 years Up to 50% repeat febrile sz Increased risk if age < 1 yr No increased epilepsy riskComplex: focal, > 15 min

duration, flurry of sz


Febrile Seizure ED Rx: Limited need for LP Sz as sole manifestation of

meningitis not seen HIB: meningitis rare Treat bacteremia (WBC > 15k) CBC, blood cx, ceftriaxone


Other Pediatric Sz TypesOther Pediatric Sz Types Neonatal seizures Benign childhood epilepsy

(Rolandic) Infantile spasms (West syndrome) Lennox-Gastaut syndrome Atonic seizures Juvenile myoclonic epilepsy (JME)


Juvenile Myoclonic Epilepsy: Common in teens, young adults Etiology of generalized TC seizures History of staring spells, AM

clumsiness, myoclonus Sleep deprivation, EtOH precipitants Valproate may be best acute Rx


Seizures in the Elderly:AMS: non-convulsive SEDrug-drug interactionsCVD, tumor, toxicitiesCaution for hypotension,

cardiac dysrhythmias, IV AED extravasation


Psychogenic Sz: Functional sz, not neurogenic Conversion disorder, not faking it Seen in 20% of epilepsy pts Neurogenic sz in up to 60% of

psychogenic sz pts: treat first! Characteristic mvmts noted


EMS Seizure Rx:Sz cause recurrent EMS needALS care for CNS findings,

unstable, high riskLow risk fractures (BB/collar) IV, PR diazepam IM midazolam


Research in Sz, SE:Treiman D: VA Coop study Alldredge B: PHTSEHuff S: ED Sz epidemiologyEFA Working Group (JAMA)Hampers L: Febrile sz ED Rx


EFA Guidelines: Protocol: ABCs, know drugs,

adequate doses Benzodiazepines, phenytoins,

phenobarb/valproate Midazolam, propofol, pentobarb Specify general timelines


SE Rx Timeline: 0-30 min: ABCs, benzos 30-45 min: Phenytoins 45-75 min: Phenobarb/valproate 75+ min: Refractory SE Rx 90-150 min: CT, EEG, ICU/OR


ACEP CPC Questions Clinical Policy Committee Written guidelines Clinically relevant questions

Role of oral loading Subtle SE, EEG use Post-benzo AED therapy in SE New onset seizure ED Rx


Sz, SE Conclusions Sz, SE: medical emergencies Early Rx is critical Many Rx options exist Maximize ED Rx

Have a plan Have meds readily available Use EEG when indicated


Slide Content Slides on FERNE website EM physicians, neuro emergencies www.FERNE.org Look for button on main page 2001 ICEP Seizure Lecture


FERNE Sz Symposium Tuesday October 16, 2001 4:00 to 6:00 pm U of Chicago Gleacher Center Clinical Issues in ED Seizure Rx Register online at www.FERNE.org

the management of seizures and se in the emergency department

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