11 Seizures

Question 1

Remarks on imaging in seizures

Answer 1

Obtain a CT scan of the head in the ED for patients with a first-ever seizure or a change in established seizure patterns to evaluate for a structural lesion.
A noncontrast CT is an appropriate screening tool.
Because many important processes, such as tumors or vascular anomalies, may not be evident on noncontrast studies, a follow-up contrast-enhanced CT or MRI is often needed.

Question 2

Indication for lumbar tap in seizures

Answer 2

Febrile
Immunocompromised
SAH is suspected

Question 3

2nd line meds for status epilepticus

Answer 3

Fosphenytoin
Phenytoin
Levetiracetam 2000 - 4000 g

Question 4

Meds for refractory status epilepticus

Answer 4

1st-line: Propofol 1 mg/kg, then infusion
2nd-line: Midazolam 0.2 mg/kg loading dose, then infusion
3rd line:
Phenobarbital 20 mg/kg
Ketamine 0.5 to 4.5 mg/kg or infusion of 5 mg/kg/hour

Also, intubate

Question 5

Remarks on phenytoin

Answer 5

Loading dose 30 mg/kg
Due to myocardial depression from its propylene glycol diluent, phenytoin is typically infused no faster than a rate of 25 mg/min (taking about 1 hour to administer)

Question 6

Definition of refractory status epilepticus

Answer 6

Persistent seizure activity despite the IV administration of adequate amounts of two antiepileptic agents and usually exceeds 60 minutes

Question 7

Remarks on propofol

Answer 7

Can be started as an infusion at tyipcal rates of 2 to 10 mg/kg/hour, and titrated up to effect of seizure cesation.
At higher doses (>40 mg/kg/h), patients are at increased risk of hemodynamic instability including hypotension as well as propofol infusion syndrome

Question 8

Remarks on midazolam

Answer 8

Can be started at 0.05 to 0.4 mg/kg/hour and is titrated up to seizure cessation
Can accumulate in peripheral soft tissues, particularly with renal insufficiency, leading to a much prolonged recovery period