SEIZURE Flashcards
MANAGEMENT: STATUS EPILEPTICUS
- CALL FOR HELP
- ABCDEFG (ABC and Don’t Ever Forget About Glucose)
AIRWAY:
Lateral decubitus/recovery position
Suction
Jaw thrust if tongue is occluding airway
Bag Mask Ventilation
+/-Oropharyngeal airway or nasal trumpet
DO NOT USE A BITE BLOCK
INTUBATION: vomiting, apneic, not protecting airway
RSI MEDS: Midazolam, Propofol or ketamine
BREATHING: O2 if necessary
CIRCULATION: MOVIES
Ensure 2x IV access
Use IM or IN medications if IV not available
DISABILITY: POC Glucose-> 1 amp D50W (+/- thiamine if hx of alcoholism) OR Glucagon 1 mg IM if IV not available
Most seizures last 1-2 minutes and self resolve
POC ABG / VBG for Sodium
EXPOSURE:
Look for signs of injury
- Rapid Neurologic Exam
- BENZODIAZEPINE
Lorazepam (Ativan): 2-4 mg IV
(0.01-0.03 mg / kg IV or IM, max 0.1 mg / kg or 8 mg)
(Onset within 2 min, lasts 4-6 hrs)
OR
Midazolam (Versed): 5-10 mg (0.05 mg / kg) IV
(10 mg IM if IV not available; IM, IN, IV or PR available)
OR
Diazepam (Valium): 5-10 mg IV (0.1 mg / kg IV)
(Onset within 30 secs, last < 20 min)
- REFRACTORY
- Give 2nd & 3rd dose of benzodiazepine
- Load with Phenytoin
20 mg/kg IV loading dose at a rate of 50 mg / min, max 1500 mg
Watch BP and telemetry for arrythmias
Do NOT use for suspected toxic overdose (lidocaine, cocaine, theophylline)
OR
KEPPRA: 40-60 mg / kg IV loading dose at a rate of 5-15 min), max 2000-4000 mg IV load
Fosphenytoin: 20 mg/kg IV loading dose at infusion of 150 mg/min
- REFRACTORY > 10 MIN
- Additional dose of phenytoin: 10 mg / kg IV (750 mg IV)
- Intubation
- Consult ICU
- 3rd Line Med:
Phenobarbitol 20 mg/kg IV at 50 mg/min
+/-
IV Propofol 1-2 mg / kg bolus, repeat q3-5 min THEN 2-10 mg /kg / hr
OR
Midazolam 0.2 mg / kg IV bolus THEN up to 0.6 mg / kg / hr IV infusion - INVESTIGATIONS
STAT Glucose
Na, Ca
BUN, Cr
LFTs
CK
BHCG
ECG - exclude Arrythmia
Anticonvulsant levels
ETOH / Tox screen
+/- blood cultures / TSH
CT head if first episode or concerning history / physical
+/- Lumbar Puncture
CONSULT:
Medicine / Neurology
MONITOR
cardiac monitor / neurovitals
hyperthermia rhabdomyolysis
lactic acidosis
MANAGEMENT: RESOLVED SEIZURE
GENERAL APPROACH
1. ABCDEFG (ABC’s and Don’t Ever Forget the Glucose)
2. Establish IV access (for medication delivery if recurrent seizure in the ED)
3. Distinguish between seizure vs seizure mimics
4. Distinguish between first seizure vs recurrent seizure
5. Categorize the seizure
6. Identify the underlying cause of seizure
7. Assess for complications of seizure
8. Assess anti-seizure drug levels
9. Disposition and discharge instructions
- DISTINGUISH BETWEEN SEIZURE VS. SEIZURE MIMIC
DDx:
Syncope
Complex Migraine
TIA
Functional Seizures
highly suggestive of seizure activity (from highest LR to lowest):
Lateral tongue-biting (100% Specific)
Lateral head rotation
Unusual posturing
Urinary incontinence
Blue skin colour observed by bystanders
Limb jerking
Prodromal trembling, hallucinations, pre-occupation or deja-vu
Amnesia for behaviors surrounding event
Postictal phase
Other:
Before: Aura, focal symptoms, automatisms
Myoclonic jerks BEFORE LOC
1-2 min
BP & HR usually ELEVATED
More often HORIZONTAL deviation of flickering of eyelids, blank stare
Eyes open
- DISTINGUISH FIRST SEIZURE VS. RECURRENT SEIZURE
Ask about in the weeks and months prior:
subtle motor jerking
positive sensory phenomena
staring spells
hallucinations - CATEGORIZE THE SEIZURE
Provoked (specific cause) or unprovoked (epilepsy)
LOC or no LOC
Motor symptoms or not (convulsive or nonconvulsive)
Focal or generalized or progress from focal to generalized
Status epilepticus (> 5min or consecutive seizures without a return to baseline in between) or not - INDENTIFY THE UNDERLYING CAUSE
FIRST: Immediate life-threats that require immediate treatment with specific antidotes:
Vital sign extremes: hypoxemia (O2), hypertensive encephalopathy (labetolol etc) and severe hyperthermia (cooling)
Metabolic: hypoglycemia (glucose), hyponatremia (hypertonic saline), hypomagnesemia (Mg), hypocalcemia (Ca)
Toxicologic: anticholinergics (HCO3), isoniazid (pyridoxine), lipophilic drug overdose (lipid emulsion) etc.
Eclampsia: typically > 20 weeks of pregnancy and up to 8 weeks postpartum (Mg)
SECOND: Identify non-lifethreatening eiology
Consider a non-contrast CT head in patients with a:
First time seizure
Prolonged postictal period or persistent altered mental status
History of malignancy, immunocompromised, bleeding disorder/anticoagulation, shunt, neurocutaneous disorder, chronic alcohol abuse
Fever
Non-trivial head injury
New focal onset seizure
Persistent focal neurological deficit
- ASSESS FOR COMPLICATIONS OF THE SEIZURE
Trauma
Hypoglycemia
Acidosis
Rhabdomyolysis
AKI
Hyperkalemia
Aspiration
Neurogenic pulmonary edema
Neurogenic Cardiac Injury - ASSESS ANTI-SEIZURE DRUG LEVELS
phenytoin
valproate
phenobarbital
carbamazepine
Send out levels:
lamotrigine
levetiracetam (Keppra)
clobazam
Academy of Neurology: first-time unprovoked seizure patients who are back to baseline and suitable for discharge do not require loading on anti-seizure medications
Levetiracetam oral load of 1,500mg in the ED followed by 500-1000mg po bid as the drug of choice for ED loading of the first time seizure patient
c/i psychiatric illness
- DISPOSITION AND DISCHARGE INSTRUCTIONS OF THE PATIENT WITH A SEIZURE
single first-time generalized seizure and otherwise normal history and physical who return to neurological baseline can be discharged home with close follow-up with outpatient neurology. If discharged, the patient should have somebody monitor them for recurrent seizure for 24hrs given the significant risk of recurrent seizure (up to 9%).
Discharge Instructions: DO NOT
swim, bathe alone or a baby in a bathtub, climb heights, operate heaving machinery or drive.
MTO REPORTING
report anyone 16 years of age or older who has had a seizure to the Ministry of Transportation regardless of whether or not they have a driver’s license
SPECIFIC ANTIDOTES
ECLAMPSIA
First Line:
Magnesium Sulfate
4-6 g IV over 20 min, followed by an infusion of 1-2 g / hr
Second Line: Benzodiazepines
Hydralazine 5-10 mg IV, repeated every 20 minutes (max 20 mg)
Labetolol 10-20 mg IV push over 2 minutes, double the dose repeated every 10 minutes (max 80 mg/dose) (max total dose 300 mg)
Delivery of Fetus
HYPOGLYCEMIA
D50 IV push (50 mL, 25 g)
HYPONATREMIA
3% NaCl, 100 mL infusion over 10 min
ISONIAZIDE
Pyridoxine (Vit B6) 1 g IV for each 1 g Isoniazid ingested
OR
5 g for an unknown ingestion
DDX
Syncope
Complex Migraine
TIA
Functional Seizures
decreased likelihood of true seizures:
SYNCOPE:
Presyncope BEFORE LOC
LOC with prolonged standing, sitting
Prodromal diaphoresis, vertigo, nausea, chest pain, feeling of warmth, palpitations or dyspnea
other:
Myoclonic jerks after LOC
EMS vitals +/- low BP & HR
Rapid recovery
Vertical eye deviation (rolling back)
PSEUDOSEIZURES
Duration greater than 5 min
Eyes Closed
Rapid recovery
Repetitive side to side movement of head
Asynchronous movements
Pelvic thrusting, bicycling movement of legs
Mental Health Issues
Fluctuating course
Moaning / talking during episode
MIGRAINE
Positive neurological symptoms march over several minutes vs. several seconds
DDX: PROVOKED SEIZURE
CENTRAL
Infectious:
Meningitis / Encephalitis
Abscess
Structural:
Intracranial Hemorrhage
Trauma
Tumor
Following Neurosurgical Procedure
Vascular Lesion
Hydrocephalus
Ischemic:
CVA
Hypoxic / Anoxic Brain Injury
Autoimmune:
Encephalitis
METABOLIC
Hypo / Hyperglycemia
Hypernatremia
Hyponatremia
Hypocalcemia
Uremia
Hepatic Encephalopathy
Thyrotoxicosis
TOXIC
Antidepressant (SSRI, SNRI, TCAs, Bupropion)
ASA
Tramadol
Isoniazid
Diphenhydramine
Theophylline
Cocaine / Amphetamine
LSD
Carbon Monoxide
WITHDRAWL
Alcohol
Antiepileptic drugs
Benzodiazepines
ECLAMPSIA
HYPERTENSIVE ENCEPHALOPATHY
