seizure management in the ed: putting it all together andy jagoda, md, facep professor of emergency...
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Seizure Management in the ED: Putting It All Together
Andy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of Medicine
New York, New York
Patient who has seized and returned to baseline
First time
yes no
Consider need for CBC, LFTs, Ca, Mg, PO4, drug of abusescreen alcohol level
same as past events
noyes
check AED levelassess for factors that lower seizure threshold
HIV + ORImmunocompromised
CT / LP
Focal neurologic exam
yes no
CT in EDCT in ED OR Arrange CT as an outpatient
Obtain electrolytes, glucosepregnancy test in woman
Assess for drug use head trauma, medical illness medications, pregnancy, hypoglycemia, focal neuro exam
Approach to pt who has sz and returned to baseline
B
CB
C
BB If on phenytoin
and subtherapuetic load with IV, POo, IM
C
Discharge for outpt workup / Do not start AEDC
Patient seizing
Assess and secure the ABCs; Protect the patient from harm; Check glucose and give dextrose if <80 Perform a physical assessment; Monitor vital signs, ECG, pulse oximetry
Assess need for:AntibioticsCharcoalToxin specific therapy (eg B6, HCO3)
Seizure stopsSee pathway I
Seizures continue
Observe and prepare for a second event
Send blood for: pregnancy test, CBC, electrolytes AED levelsConsider sending blood for: Mg, Ca, PO4, LFTs, ETOH, toxicology screen / levels
Lorazepam, 2 mg / min to a max of 10 mg(.1 mg/kg in children)
sz# stops sz continues
Phenytoin 18 mg / kg at 25-50 mg / min##orFosphenytoin 18 PE */ kg at 150 mg / min
sz stops sz continues
Repeat phenytoin or fosphenytoin at 1/2 the initial doseor phenobarbital 20 mg / kg at 100 mg / min
sz stops sz continues
Clinical pathway for status epilepticus
C
C
C
Observe Prepare for another seizure Pentobarbital,** 3-5 mg / kg at 25 mg / min then drip at .5 - 3 mg / min
orMidazolam 200 ug / kg bolus then 1-10 ug / kg / minorPropofol 1-2 mg / kg bolus then 2-10 mg/kg/hr
Consider bedside EEG
Reassess patientIntubate at any time airway or breathing is compromisedConsider CT / LP
# sz = seizure
## slower rates for patients with cardiovascular disease. infusion shouldbe through a large bore IV
* PE = phenytoin equivalent
** watch for hypotension and treat initially with fluids; dopamine if needed
AED = antiepileptic drug
C
C
Andy Jagoda, MD
1:00 AM: EMS Called for a Patient Seizing
• Witnesses report that patient druank 3-6 beers
• Patient ingested a “dot” of LSD 2 hours prior to EMS
• Patient asked for “help” then fell to floor seizing
• No history of trauma• No other history available
Andy Jagoda, MD
1:10 AM: EMS Arrived and Called for Activation of Seizure Protocol
• Patient in status epilepticus• BP 130/90, RR 20, P 110• Dextrostix 120• Pulse oximetry 98% saturation• IV access established• Diazepam 5 mg IV Q 5 min to a max
of 20 mg • Estimated ETA: 20 minutes
Andy Jagoda, MD
1:30 AM: Patient Arrived in the ED Seizing
• Diazepam 20 mg given in the field
• BP 130/90, P 110, RR 20, Rectal T 37
• BS and Pulse Ox unchanged
Andy Jagoda, MD
Physical Exam
• Tonic clonic activity
• WDWN: No evidence of immunocompromise
• No signs of trauma
• No signs of intravneous drug use
• Unresponsive to verbal or painful stimuli
Andy Jagoda, MD
Physical Exam
• PERL: Dilated to 8 mm
• Gaze away from the
examiner
• Gag intact
• No incontinence
Andy Jagoda, MD
PHYSICAL EXAM
THE VIDEO
The Results of a Diagnostic Test was
Obtained
Andy Jagoda, MD
Laboratory Tests
• Electrolytes: NA 143, K 4.1, CL 108, HCO3 24
• Alcohol: 120 mg/dl• CPK: 240 ng/mL• Tox Screen for DOA: Normal
Arterial Blood Gas: pH 7.44, pO2 110, pCO2 36, 100% saturation
Andy Jagoda, MD
A Dx of Psychogenic Status Epilepticus was Made
• Patient was given verbal suggestions that the seizures would stop if he concentrated
• While still “seizing” the patient began to cry for help
• Over 10 minutes the “seizures” slowly subsided
Andy Jagoda, MD
Past Medical History• Similar but brief event since age 10
• Focal• Controlled with concentration
• Events always occurred in association with stressful situations
• Emotional and physical abuse as a child• Father beat him • Chained to the bed
• Presently under stress from losing job
Andy Jagoda, MD
The LSD “Trip”
• Recalled initial euphoric feeling
• Recalled floating sensation
• Followed by strong visual distortions
• Remembers becoming panicked that he could not control himself
• Remembers the seizure and all care given
Andy Jagoda, MD
Physical Findings Suggestive of Psychogenic Seizures
• Out of phase movements
• Pelvic thrusting
• Head turning side to side
• Dilated pupils, reactive to light
Andy Jagoda, MD
Howell et al. Pseudostatus epilepticus. Q J Med. 1989;71:507-519
• 40% of patients transferred in “status epilepticus” were in psychogenic status
• Estimated 5% TO 20% of patients referred to epilepsy centers have psychogenic seizures
Andy Jagoda, MD
Criteria for a Conversion Disorder
• Alteration in physical functioning
• Psychological factors involved
• Symptoms are not unders voluntary control
• Symptoms are not explained by a physical disorder
Andy Jagoda, MD
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
Andy Jagoda, MD
Conclusions
• In refractory status epilepticus, pentobarbital, midazolam, or propofol are third line agents
• Psychogenic seizures are characterized by out of phase motor activity, forward pelvic thrusting, voluntary eye movements, normal mental status
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