Seizure/Status Epilepticus

Question 1

Provoked etiologies of SE

Answer 1

intoxication, withdrawal from EtOH or BZDs, trauma, meningitis, psychiatric, metabolic derangements

Question 2

Unprovoked etiologies of SE

Answer 2

more difficult to determine cause, may or may not need treatment with antiepileptic medications

Question 3

Physiology of seizures

Answer 3

brain has normal inhibitory mechanisms that prevent seizures and terminate seizures that do occur, but in a seizure, they’re out of balance

Question 4

Inhibitory neurotransmitter

Answer 4

GABA

Question 5

Excitatory neurotransmitters

Answer 5

glutamate, aspartate, ACh

Question 6

First-line agents for seizures

Answer 6

BZDs to STOP the seizures
AEDs to PREVENT the seizures from occurring again

Question 7

BZDs used in SE

Answer 7

lorazepam, diazepam, midazolam

Question 8

AEDs used in SE

Answer 8

Phenytoin/fosphenytoin, Keppra, VPA

Lacosamide as add-on treatment

Question 9

Meds used in refractory SE

Answer 9

Pentobarbital, phenobarbital

Question 10

Med used in super-refractory SE

Answer 10

Ketamine

Question 11

Goal of therapy in SE

Answer 11

achieve rapid and safe termination of the seizure, prevent seizure recurrence, avoid ADRs on the CV or respiratory systems

Question 12

Burst suppression on LTM

Answer 12

Monitor for 24-48 hours, then IV infusions are titrated off while monitoring for seizure returns

Question 13

What to do after burst suppression

Answer 13

Slowly wean IV infusions based on LTM reading
Usually wean agents that are causing ADRs or need for other interventions
Increase doses if seizures return

Question 14

Meds to titrate off first after a burst suppression

Answer 14

Phenobarbital, pentobarbital, propofol, midazolam

Question 15

SE treatment algorithm: stage 1- 0-10 minutes

Answer 15

Take care of airway, breathing, circulation, lab tests, IV thiamine followed by dextrose
Lorazepam 2-4mg IV, repeat PRN OR midazolam 10mg IM, repeat PRN

Question 16

SE treatment algorithm: stage 2- 10-30 minutes

Answer 16

Phenytoin 20mg/kg IV OR fosphenytoin 20mg/kg PE IV
Can give additional 5-10mg/kg of either

Other options:
VPA 20-30mg/kg IV OR phenobarbital 20mg/kg IV OR Keppra 20-60mg/kg

Question 17

SE treatment algorithm: stage 3- 30-90 minutes

Answer 17

Midazolam load 0.2mg/kg IV infusion (0.2-0.6mg/kg/hr) OR propofol load 2mg/kg IV infusion (2-5mg/kg/hr)

Question 18

SE treatment algorithm: stage 4: 90 mins-hours/days

Answer 18

Phenobarbital load 5mg/kg IV infusion (1-5mg/kg/hr)

Question 19

Refractory SE definition

Answer 19

Seizures lasting >2 hours OR seizures recurring at a rate of 2 or more episodes/hr without recovery to baseline between seizures, despite treatment with conventional antiepileptics

Question 20

Refractory SE treatment

Answer 20

High-dose BZDs: midazolam bolus and infusion
2mg IV bolus + 2mg/hr, increase PRN up to 2mg/kg/hr
If this doesn’t work, you can continue to double the dose (so next time it will be 4mg IV bolus + 4mg/kg/hr, etc.)

Propofol IV infusion

Phenobarbital or pentobarbital coma

Question 21

Post-intubation treatment

Answer 21

Paralytic is used during intubation so seizures aren’t going to be physically observed

Start IV infusion of propofol or midazolam

At this point, patients are generally on 2-3 IV anti epileptics and at least one continuous IV infusion