SEIZURE MANAGEMENT

Question 1

Status Epilepticus Definition

Answer 1

Seizure lasting > 5 min
OR
Seizures without returning to baseline

Question 2

Approach to Status Epilepticus

Answer 2

Monitor
Oxygen
Vitals
IV / IO Access
Equipment: Airway, Suction

POC GLUCOSE STAT

AIRWAY / BREATHING: Airway maneuvers Sucitoning secretions Supplemental oxygen
Continuous pulse oximetry
Lateral decubitus position

Consider intubation in patients who are apneic, hypoxic, vomiting, nor protecting airway

RSI:
Midazolam 0.2 mg / kg IV

Fentanyl 1-4 mcg / kg IV / IO

Propofol IV: 2.5 to 3.5 mg/kg over 20 to 30 seconds
OR
Ketamine 1-2 mg / kg

Rocuronium: 0.6 - 1.2 mg / kg IV

CIRCULATION
IV / IO Access

DISABILITY
POC Glucose Stat
POC ABG / VBG for Sodium

Abort Seizure:

Midazolam:
0.2 mg / kg IV / IO
0.2-0.5 mg / kg IM

Lorazepam:
0.05 - 0.1 mg / kg
max 4 mg IV / IO / IM

Reduce temperature if febrile

Rapid Neurological Exam:
Evaluate for focal signs, including asymmetric pupils or asymmetric neurologic exam

EXPOSURE:
Evaluate for signs of trauma

Question 3

Active Seizure Management: Benzodiazepine doses (give 3 options)

Answer 3

Midazolam:
0.2-0.5 mg / kg IM
0.2 mg / kg IM / IO

Lorazepam:
0.05 - 0.1 mg / kg, max 4 mg IV / IO / IM

Diazepam:
0.5 mg / kg Rectal
0.15 - 0.2 mg / kg IV / IO max 10 mg

Give 2-3 doses prior to initiation of the 2nd line agent

Question 4

Preferred 2nd line agent: dose, route, duration before switching to 3rd line agent

Answer 4

Established Status Epilepticus Treatment Trial: several 2nd line meds have similar efficacy

Levetiracetam: 20-60 mg / kg (40 mg / kg) IV loading dose

Valproate 20 mg /.kg IV / IO caution in age
< 2 y

Phenytoin 15-20 mg / kg IV / IO, infuse 1-3 mg / kg / min

Fosphenytoin 20 mg Phenytoin Equivalents IV

Phenobarbitol
20 mg / kg IV / IO (first line in neonates)
Keppra (Levetiracetam) 20-60 mg / kg IV / IO

Question 5

Preferred 3nd line agent: dose, route, duration before considering infusion / next steps

Answer 5

Phenobarbitol
20 mg / kg IV
30 min

Propofol

Ketamine

Consider intubation and infusion

Question 6

DDx: Recalcitrant Seizures

Answer 6

Trauma

Isoniazid / Toxic Exposure (consider BB, EtoH

Infection

Hypocalcemia
Hyponatremia

Inborn Errors of Metabolism

Eclampsia

Question 7

Hypoglycemia

Answer 7

Neonatal: 2 ml / kg D10 IV

Infant 5 mL / kg D10 IV

Children / Adolescents (“Rule of 50”):
1 ml / kg D50 IV
2 ml / kg D25 IV
5 ml / kg D10 IV

Question 8

Hypocalcemia

Answer 8

Calcium gluconate 10% 50-100 mg / kg IV
OR
1/3 ml / kg IV

Question 9

Hyponatremia

Answer 9

NaCl 3% 3-5 ml/kg slowly

Question 10

Isoniazid

Answer 10

Pyridoxine:

100 mg / dose IV

Question 11

Disposition: Discharge Home

Answer 11

Anti-epileptic drugs do not need to be started for first-time nonfebrile seizures or for febrile seizures.

Febrile Seizure with Full Recovery and Non-toxic

First-time non febrile seizure with reliable monitoring and follow up

First-time non febrile seizure need outpatient EEG and MRI

Cautioned against bathing, swimming, or other activities that may be dangerous. Teens must be cautioned against driving.

Question 12

Disposition: Admission

Answer 12

Prolonged post-ictal or AMS - consider non convulsive status

All neonates

Urgent neurology consult