Clinical Decisions in the Management of Seizures and Status Epilepticus in the Emergency Department Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York - PowerPoint PPT Presentation

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Clinical Decisions in the Management of Seizures and Status Epilepticus in the Emergency Department Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York

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Title: Clinical Decisions in the Management of Seizures and Status Epilepticus in the Emergency Department Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York


1
Clinical Decisions in the Management of Seizures
and Status Epilepticus in the Emergency
Department Andy Jagoda, MD, FACEP Professor
of Emergency Medicine Mount Sinai School of
Medicine New York, New York
2
A 20 year old female with no known medical
problems has a generalized tonic clonic seizure
that lasts 2 minutes. After a short postictal
period, she returns to her baseline, feels well,
has a normal physical and neurologic exam. Which
of the following laboratory tests is not
indicated in the ED?
  • Pregnancy test
  • Electrolytes
  • Glucose
  • CSF analysis
  • CT

3
The patient is worked-up as an outpatient and
diagnosed with a seizure disorder. She is
treated with phenytoin, 300 mg qhs. She is
brought to the ED by EMS status post a typical
event but back to baseline. Her serum phenytoin
level is lt1 ug/ml. Which of the following is the
best management plan?
  • Fosphenytoin, 20 PE/kg, IM in the deltoid
  • Fosphenytoin, 20 PE/kg, IV at 300 mg/min
  • Phenytoin, 20 mg/kg IV at 150 mg/min
  • Phenytoin, 20 mg/kg po and discharge after 4 hrs
  • Lorazepam, 2 mg, IV and discharge after one hour

4
While in the ED, she goes into status
epilepticus. The seizures do not stop despite
lorazepam, 10 mg, and phenytoin 20 mg/kg. Which
of the following is not a reasonable third line
therapy?
  • A second half load of phenytoin (10 mg /kg)
  • Phenobarbital, 20 mg / kg
  • Pentobarbital, 3 mg / kg
  • Propofol, 1 mg / kg
  • Vecuronium, .1 mg /kg

5
INTRODUCTION
  • Classification
  • Focal vs Generalized
  • Motor vs Nonmotor
  • Etiologies Key is to identify treatable causes
  • Vascular event (stroke, SAH, subdural)
  • Metabolic abnormality (hypoglycemia)
  • Infections
  • Toxicity (intentional, nonintentional)
  • Drug withdrawal
  • Tumor
  • Pregnancy

6
Seizures in Pregnancy
  • Evaluation same as in the non pregnant patient
  • Evaluation should focus on precipitating factors
    (sleep deprivation, AED noncompliance, stress)
  • Pregnancy changes AED free drug levels
  • Fetal monitoring must be included
  • Assess for eclampsia
  • Mg SO4 therapy of choice in eclamptic szs

Lancet 1995 3451455-1463
7
Seizures in Adults
  • New onset sz highest incidence patients lt 1 yr
    and gt 60 yrs
  • 50 of szs in the elderly are related to stroke
  • Tumors and drugs/alcohol
  • NCSE presents as confusion or altered mental
    status
  • Etiology often unknown but may result from
    stroke, drug withdrawal or electrolyte
    abnormalities

8
New Onset Seizures
  • 5 - 6 of the population will have at least one
    seizure during their lifetime
  • Diagnostic work-up in the ED depends on the
    clinical exam and co-morbidities
  • Etiologies of first time adult seizures are age
    group dependent and co-morbidity dependent
  • HIV
  • Chronic alcohol consumption (30-60 year olds)
  • Cerebral vascular insults (gt60 year old)

9
A 20 year old female with no known medical
problems has a generalized tonic clonic seizure
that lasts 2 minutes. After a short postictal
period, she returns to her baseline, feels well,
has a normal physical and neurologic exam. Which
of the following laboratory tests is not
indicated in the ED?
  • Pregnancy test
  • Electrolytes
  • Glucose
  • CSF analysis
  • CT

10
What laboratory tests are indicated in the ED
evaluation of a patient with a new onset sz?
  • ACEP Clinical Policy. Ann Emerg Med 1997 29706
  • Patients with a normal exam and no co-morbities
    Glucose level, electrolytes, and pregnancy test
  • Consider a drug of abuse screen
  • Patients with co-morbidities require more
    extensive testing
  • CPK and prolactin levels are of limited value in
    the ED

Turnbull. Utility of laboratory studies in the ED
in patients with a new onset sz. Ann Emerg Med
1990 19373-377. Prospective. 136
patients) Nypaver. ED laboratory evaluation of
hcildren with seizures Dogma or dilemma? Ped
Emerg Care 1992 813-21. Retrospective 308
patients)
11
Lumbar Puncture
  • A LP in the ED is not indicated if the patient
  • Is not immunocompromised
  • Has returned to baseline
  • Has no fever or meningeal signs
  • There are no cases reportedof meningitis
    presenting as a simple tonic clonic seizure
  • Postictal pleocytosis (gt5 polys in the CSF) has
    been reported in 2 - 18 of patients who have had
    a GTCS

Pesola G,. New onset generalized seizures in
patients with AIDS. Acad Emerg Med. 1998
5905-911. Retrospective review, 26
patients Green S,. Can seizures be the sole
manifestation of meningitis in febrile children?
Pediatrics 1993 92527-534. Retrospective. 503
cases
12
Neuroimaging Head CT and MR
  • Three per cent to 41 of patients with a first
    time seizure have an abnormal head CT
  • Imaging is dependent on the urgency of the
    evaluation and patient stability
  • Literature interpretation depends on outcome
    measure used

Tardy. AJEM. 1995 131-5. Retrospective review.
247 patients. Henneman AEM 1994 241108-1114.
Retrospective. 294 patients).
13
Neuroimaging in New Onset Seizures
  • ACEP, AAN, AANS, ASNR. Practice Parameter ED
    neuroimaging in the seizure pt. Ann Emerg Med
    1996 27114-118. Evidence based practice
    guideline
  • Emergent CT for patients with altered mental
    status, trauma, focal exam, immunocompromise,
    fever, co-morbitidity
  • Patients who are alert with a nonfocal exam can
    have an outpatient study
  • Focal abnormalities on CT are reported in up to
    40 of patients with new onset seizures up to
    20 have non-focal exams
  • MRI is better than CT in detecting subtle lesions
    (e.g., hippocampal sclerosis) but impact on care
    is controversial

14
Treatment of First Time Seizures
  • Coordinated care with neurologist / primary care
    provider
  • Decision to initiate AED treatment depends on the
    risk of recurrence, ie, etiology
  • Etiology, CT and EEG findings are the strongest
    predictors
  • Recurrence risk is up to 20 within the first 24
    hours
  • 23 to 71 within 2 years
  • Patients needing immediate AED treatment can be
    loaded with oral or IV phenytoin IM
    forphenytoin IV valproic acid
  • Decision to admit depends on assessed risk of
    recurrence, patient compliance, and patients
    social circumstances

15
The patient is worked-up as an outpatient and
diagnosed with a seizure disorder. She is
treated with phenytoin, 300 mg qhs. She is
brought to the ED by EMS status post a typical
event but back to baseline. Her serum phenytoin
level is lt1 ug/ml. Which of the following is the
best management plan?
  • Fosphenytoin, 20 PE/kg, IM in the deltoid
  • Fosphenytoin, 20 PE/kg, IV at 300 mg/min
  • Phenytoin, 20 mg/kg IV at 150 mg/min
  • Phenytoin, 20 mg/kg po and discharge after 4 hrs
  • Lorazepam, 2 mg, IV and discharge after one hour

16
AED Loading
  • In patients who have seized and returned to
    baseline, no AED loading strategy has been shown
    to be superior in preventing seizure recurrence
  • No outcome studies exist comparing loading
    strategies
  • IV phenytoin achieves therapeutic serum levels by
    the end of the infusion
  • IM fosphenytoin achieves therapeutic serum levels
    within one hour post injection
  • PO phenytoin, 19 mg/kg in males and 25 mg/kg in
    females single dose achieves therapeutic serum
    levels in 4 hours

Ratanakorn. J Neuro Sci 1997 14789-92 Van der
Meyden. Epilepsia 1994 35189-194
17
Valproic Acid Loading
  • 15 mg / kg oral, rectal, or intravenous
  • Oral loading rapid absorption but limited by GI
    side effects
  • IV loading recommended over one hour
  • Has been given faster at 200 mg / min in status
    epilepticus as a third line drug

Drug Invest 1993 5154-159
18
The patient is worked-up as an outpatient and
diagnosed with a seizure disorder. She is
treated with phenytoin, 300 mg qhs. She is
brought to the ED by EMS status post a typical
event but back to baseline. Her serum phenytoin
level is lt1 ug/ml. Which of the following is the
best management plan?
  • Fosphenytoin, 20 PE/kg, IM in the deltoid
  • Fosphenytoin, 20 PE/kg, IV at 300 mg/min
  • Phenytoin, 20 mg/kg IV at 150 mg/min
  • Phenytoin, 20 mg/kg po and discharge after 4 hrs
  • Lorazepam, 2 mg, IV and discharge after one hour

19
While in the ED, she goes into status
epilepticus. The seizures do not stop despite
lorazepam, 10 mg, and phenytoin 20 mg/kg. Which
of the following is not a reasonable third line
therapy?
  • Midazolam, .2 mg/kg .1 mg/kg/hr
  • Phenobarbital, 20 mg / kg
  • Pentobarbital, 5-15 mg / kg 2 mg/kg/hr
  • Propofol, 1 mg / kg 4 mg/kg/hr
  • Vecuronium, .1 mg /kg

20
Status Epilepticus
  • 126,000 - 195,000 cases in the US / year
  • 25 of cases are NCSE or SGCSE
  • 22 mortality in convulsive status
  • 26 in adults, 3 in children
  • Undetermined in NCSE or SGCSE
  • M M associated with
  • Underlying etiology
  • Co-morbidity
  • Duration of event

21
STATUS EPILEPTICUS SE Working Group (Consensus
Document)
  • Management must simultaneously address
  • Stabilization ABCs
  • Diagnostic testing including (including rapid
    glucose)
  • Pharmacologic interventions
  • Drug therapy
  • Lorazepam .1 mg/kg at 2 mg/min
  • If diazepam is used, phenytoin must be started
    simulatneously
  • Phenytoin 20 mg/kg at 25-50 mg/min (fosphenytoin
    20 PE/kg at 150 mg/min)
  • Repeat phenytoin 5 mg/kg
  • Phenobarbital 20 mg/kg at 100 mg/min
  • Valproic acid 20 mg/kg

Epilepsy Foundation of America. JAMA
1993270854-859
22
VA Cooperative Study
  • Prospective study 384 patients in CSE
  • Four treatment regimens
  • Phenytoin 18 mg/kg
  • Diazepam plus phenytoin
  • Phenobarbital 15 mg/kg
  • Lorazepam .1 mg/kg
  • No difference among the four groups in recurrance
    of seizures or mortality at 12 hours or 30 days
  • Trend in favor of lorazepam easiest to use

NEJM 1998339792-798
23
Differential Diagnosis of a Prolonged Postictal
State
  • Intracranial catastrophe
  • Hypoglycemia
  • Drug effect
  • SCSE
  • NCSE

24
Nonconvulsive Status Epilepticus
  • NCSE vs SCSE
  • Prognosis worse with SCSE
  • Clinical characteristics
  • mild cognitive deficits to coma
  • Incidence 14 after CSE
  • Diagnosis Clinical and EEG
  • Treatment

Tomson. Epilepsia 199233829-835 DeLorenzo.
Epilepsia 1998 39833-840
25
EEG in the Emergency Department
  • A properly performed EEG is helpful in
    establishing etiology and directing therapy
  • A normal EEG Does not exclude an epileptic
    focus
  • EEG in the ED
  • Patients with altered MS suspected of NCSE or
    SCSE
  • Patients who are paralyzed or in pentobarbital
    coma
  • Seizing patients suspected of being in
    psychogenic status epilepticus

26
Refractory Status Epilepticus
  • Systematic review of the literature
  • 28 studies 193 patients
  • 48 mortality
  • Compared propofol, midazolam, and pentobarbital
  • Outcome EEG burst suppression
  • Pentobarbital (13mg/kg load followed by 2
    mg/kg/hr infusion) found to be more effective but
    associated with higher incidence of hypotension

Claassen. Epilepsia 2002 43146-153.
27
While in the ED, she goes into status
epilepticus. The seizures do not stop despite
lorazepam, 10 mg, and phenytoin 20 mg/kg. Which
of the following is not a reasonable third line
therapy?
  • Midazolam, .2 mg/kg .1 mg/kg/hr
  • Phenobarbital, 20 mg / kg
  • Pentobarbital, 5-15 mg / kg 2 mg/kg/hr
  • Propofol, 1 mg / kg 4 mg/kg/hr
  • Vecuronium, .1 mg /kg

28
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
  • In refractory status epilepticus, pentobarbital,
    midazolam, or propofol are third line agents
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