Seizure Management in the ED: Putting It All Together Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York

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Seizure Management in the ED Putting It All
TogetherAndy Jagoda, MD, FACEPProfessor of
Emergency MedicineMount Sinai School of
MedicineNew York, New York
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Approach to pt who has sz and returned to baseline
Patient who has seized and returned to baseline
First time
yes
no
B
same as past events
Assess for drug use head trauma, medical illness
medications, pregnancy, hypoglycemia, focal
neuro exam
yes
no
C
B
Obtain electrolytes, glucose pregnancy test in
woman
check AED level assess for factors that lower
seizure threshold
C
Consider need for CBC, LFTs, Ca, Mg, PO4, drug
of abuse screen alcohol level
C
HIV OR Immunocompromised
Focal neurologic exam
If on phenytoin and subtherapuetic load with IV,
POo, IM
B
no
yes
B
CT / LP
CT in ED OR Arrange CT as an outpatient
CT in ED
C
Discharge for outpt workup / Do not start AED
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Patient seizing
Clinical pathway for status epilepticus
Assess and secure the ABCs Protect the patient
from harm Check glucose and give dextrose if lt80
Perform a physical assessment Monitor vital
signs, ECG, pulse oximetry
Assess need for Antibiotics Charcoal Toxin
specific therapy (eg B6, HCO3)
Send blood for pregnancy test, CBC,
electrolytes AED levels Consider sending
blood for Mg, Ca, PO4, LFTs, ETOH,
toxicology screen / levels
Seizures continue
Seizure stops See pathway I
C
Lorazepam, 2 mg / min to a max of 10 mg (.1
mg/kg in children)
sz continues
sz stops
C
Phenytoin 18 mg / kg at 25-50 mg /
min or Fosphenytoin 18 PE / kg at 150 mg / min
sz stops
sz continues
C
Repeat phenytoin or fosphenytoin at 1/2 the
initial dose or phenobarbital 20 mg / kg at 100
mg / min
sz stops
sz continues
Observe and prepare for a second event
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C
Observe Prepare for another seizure
Pentobarbital, 3-5 mg / kg at 25 mg / min then
drip at .5 - 3 mg / min or Midazolam 200 ug / kg
bolus then 1-10 ug / kg / min or Propofol 1-2 mg
/ kg bolus then 2-10 mg/kg/hr
C
Consider bedside EEG
Reassess patient Intubate at any time airway or
breathing is compromised Consider CT / LP
sz seizure slower rates for patients with
cardiovascular disease. infusion shouldbe through
a large bore IV PE phenytoin equivalent
watch for hypotension and treat initially with
fluids dopamine if needed AED antiepileptic
drug
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100 AM EMS Called for a Patient Seizing

• Witnesses report that patient druank 3-6 beers
• Patient ingested a dot of LSD 2 hours prior to
  EMS
• Patient asked for help then fell to floor
  seizing
• No history of trauma
• No other history available

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110 AM EMS Arrived and Called for Activation of
Seizure Protocol

• Patient in status epilepticus
• BP 130/90, RR 20, P 110
• Dextrostix 120
• Pulse oximetry 98 saturation
• IV access established
• Diazepam 5 mg IV Q 5 min to a max of 20 mg
• Estimated ETA 20 minutes

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130 AM Patient Arrived in the ED Seizing

• Diazepam 20 mg given in the field
• BP 130/90, P 110, RR 20, Rectal T 37
• BS and Pulse Ox unchanged

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Physical Exam

• Tonic clonic activity
• WDWN No evidence of immunocompromise
• No signs of trauma
• No signs of intravneous drug use
• Unresponsive to verbal or painful stimuli

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Physical Exam

• PERL Dilated to 8 mm
• Gaze away from the examiner
• Gag intact
• No incontinence

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PHYSICAL EXAMTHE VIDEO
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The Results of a Diagnostic Test was Obtained
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Laboratory Tests

• Electrolytes NA 143, K 4.1, CL 108, HCO3 24
• Alcohol 120 mg/dl
• CPK 240 ng/mL
• Tox Screen for DOA Normal
• Arterial Blood Gas pH 7.44, pO2 110, pCO2 36,
  100 saturation

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A Dx of Psychogenic Status Epilepticus was Made

• Patient was given verbal suggestions that the
  seizures would stop if he concentrated
• While still seizing the patient began to cry
  for help
• Over 10 minutes the seizures slowly subsided

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Past Medical History

• Similar but brief event since age 10
• Focal
• Controlled with concentration
• Events always occurred in association with
  stressful situations
• Emotional and physical abuse as a child
• Father beat him
• Chained to the bed
• Presently under stress from losing job

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The LSD Trip

• Recalled initial euphoric feeling
• Recalled floating sensation
• Followed by strong visual distortions
• Remembers becoming panicked that he could not
  control himself
• Remembers the seizure and all care given

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Physical Findings Suggestive of Psychogenic
Seizures

• Out of phase movements
• Pelvic thrusting
• Head turning side to side
• Dilated pupils, reactive to light

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Howell et al. Pseudostatus epilepticus. Q J Med.
198971507-519

• 40 of patients transferred in status
  epilepticus were in psychogenic status
• Estimated 5 TO 20 of patients referred to
  epilepsy centers have psychogenic seizures

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Criteria for a Conversion Disorder

• Alteration in physical functioning
• Psychological factors involved
• Symptoms are not unders voluntary control
• Symptoms are not explained by a physical disorder

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Conclusions

• Management of a patient with a first time seizure
  is based on a careful neurologic exam, and the
  results of a chemistry panel, head CT, and EEG
• Oral phenytoin loading provides therapeutic
  serum levels four hours post-load in most cases
• Lorazepam is the best first line treatment for
  seizures

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Conclusions

• In refractory status epilepticus, pentobarbital,
  midazolam, or propofol are third line agents
• Psychogenic seizures are characterized by out of
  phase motor activity, forward pelvic thrusting,
  voluntary eye movements, normal mental status