2. Objective To know the causes and classification of seizure How to approach a seizing patient Management of seizing pt Case scenarios Seizure caused by toxins Seizure in pregnancy Febrile aizure
3. Introduction A seizure is the clinical manifestation of excessive, abnormal cortical neuronal activity. Primary vs secondary (reactive) Generalized vs partial
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5. Reactive seizures in adults Seizures caused by metabolic derangement Seizures caused by infectious diseases Seizures caused by drugs and toxins Seizures caused by trauma Seizures associated with malignancy or vasculitis Seizures caused by strokes, AVM and migraines Seizures caused by degenerative disease of the CNS Gestational seizure
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7. Status epilepticus Serial seizure activity without interictal recovery or prolonged, continuous seizure activity. Overall 30 day mortality for patients with generalized status epilepticuswas 19-27% The most common cause of status epilepticus is discontinuation of AEM.
9. The Seizing Patient Case I: First time seizure presenting to ER, seizure resolved by time off arrival Was this truly a seizure?
10. seizure Abrupt onset Brief duration Altered mental status Purposeless activity Unprovoked Post-ictal state
11. Syncope classically masquerades as seizure and may include body movements 1) Clues that episode may have been syncope: Brief episode of unconscousness followed by rapid return of mental staus 2) Clues that episode may have been seizure:Bowel/bladder incontinence, presence of post-ictalconfusional period
12. Perform thorough history and physical looking for clues to conditions that may lead to seizures: Review history for use of drugs Review history for neurological symptoms suggesting focal disease: Ask about any changes in mental status, motor or sensory function Perform physical exam: Examine head and tongue for signs of trauma Examine for focal neuro deficits may point to speficic brain lesion as etiologyof seizures: Focal motor or sensory deficits, ocular movement abnormalities, gait instability, pronator drift
13. Lab testing: Blood sugar, PT, urea and electrolytes ECG CT brain EEG Should Anti-Epileptics be started from the Emergency Department?
14. Case II Patient with known H/O seizure presenting to ER Seizure resolved by time off arrival Drug level: If anti-epileptic dug can be measured and is at subtherapeuticlevels If anti-epileptic drug can be measured and is at therapeutic levels If anti-epileptic drug cannot be measured
15. Case III Paramedics call with status epilepticus notification 54 yrs old male found seizing at home, tonic clonic type pattern Negative PMHx and family Hx RBS 100 BP 180/100, HR 110/min, RR 20 Paramedics have attempted multiple IV, all attempts failed Paramedics call for orders; what is your response?
16. Case III Status epilepticus: Pre-Hospital: no IV access: IM midazolam 0.2mg/kg to 10mg max Buccalmidazolam 0.2mg/kg to 10mg max Rectal diazepam 0.5 mg/kg to 20 mg max
18. Case III, cont, Paramedics have given lorazepam 2mg IV Pt started seizing again as paramedics pull into ED What is next action: RSI Fosphenytoin Lorazepam 2-4 mg iv Diazepam 5-10 mg iv
19. Rapid assessment and stabilization A B C D Lorazepam Paediatric dose: 0.1mg/kg bolus Adults: 2-4mg bolus May repeat twice prn
20. Midazolam Highly lipophilic drug: May be given intramuscularly or across mucous membranes with high resultant peak serum levels Fast onset of action Heat stable and easily stored for EMS use
21. Diazepam Highly lipophilic drug Available as gel with good efficacy when given via rectal route Heat stable and easily stored for EMS use Will control seizures when given intravenously May be less optimal than lorazepam
22. Lorazepam Less lipophilic properties-not optimal when given via intramuscular route Longer redistribution half life over diazepam as less lipophilic Heat labile and should be refrigerated for long term storage If given in adequate doses, will terminate seizures in 90% patients Allow 5 minutes to assess for drug efficacy Once 8-12 mg of lorazepam given and patient still seizing: Defines refractory status epilepticus and time to move to new drug
23. Case III, cont, Pt continues to seize despite administration of 12 mg lorazepam What is next? Phenytoin IV Phosphenytoin
30. Third line approach Many experts/pathways are now placing IV valproate and levetiracetam before use of phenobarbital.
31. Third line approach Valproate IV Classic anti-epileptic drug that also stabilizes sodium channels IV form now available and has been found effective in refractory status epilepticus 20 mg/kg bolus Max rate 5mg/kg/min or 300mg/min Can cause hepatotoxicity
32. Levetiracetam Newer anti-epileptic drug that has multiple sites of action: Blocks calcium dependent neurotransmitter release and modulates GABA receptors IV Formulation is now approved in adults Pediatric use not FDA approved 20 mg/kg bolus Max rate 5mg/kg/min or 300mg/min
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36. Phenobarbital Multiple effects include GABA mediated neuronal depression Still considered first line therapy in treating seizures in neonates Advantages include rescue therapy in refractory status epilepticus unresponsive to other medications 20mg bolus Max rate 1-2mg /kg /min or 50-100 mg/min Prepare for intubation Phenobarbital can cause high rate of hypotension IV fluids should be given simultaneously Pressors may also be needed to maintain blood pressure
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39. Special scenarios 1) Sympathomimetics: Classic is cocaine Maximize benzodiazepines dosages Phenobarbital indicated instead of phenytoin for second line therapy 2) Alcohol Withdrawal Seizures: Maximize benzodiazepine dose Phenobarbital indicated instead of phenytoin for second line therapy
40. 3) Other specific drugs that may cause seizures: Generally initiate therapy with benzodiazepine Phenobarbital generally indicated as second line agent over pheytoin
41. Case IV 28-yrs old female present to ED with h/o seizure PMHX – NSVD 3 weeks ago Has second seizure in ED What is your order?
42. Pregnancy Seizures may be sign of eclampsia after 20 weeks gestation May occur post-partum in segment of affected patients Load with 4-6 grams magnesium sulfate Continue infusion with 1-2 grams per hour
43. Febrile seizure in children Seizure occurring in the presence of fever without CNS infection or other cause Occurs in 2 to 5% of all children between the age of 6 months and 5 years Simple vs complex
44. Uncomplicated seizure: Duration of less than 15 minutes in child 6 months to 5 years Usually tonic-clonic, without focality Related more to rate of rise in temperature, rather than absolute temperature Usual care-no specific seizure workup Perform infection workup as indicated Complicated seizure: Duration greater than 15 minutes Focality to seizure presentation Occurring in children before age 6 months and after 5 years May require specific seizure workup (CT, LP)
45. Conclusion Seizure is a common disease in routine Emergency Medicine practice Newer second generation medications increasingly used Serum levels cannot be rapidly obtained in Emergency Department Neurology input may be needed to modulate doses
46. Conclusion Status Epilepticus: Newer definition has shortened duration of seizure activity to 5 minutes Aggressive therapy to rapidly break seizures crucial As seizures become prolonged-more difficult to control (kindling theory) IV formulations of valproate and levetiracetam now available Preliminary studies suggest role for these agents in refractory status epilepticus before intitatingphenobarbital
47. Conclusion Drug Related Seizures (intoxications, withdrawal): Majority Toxicology concensus is to first maximize benzodiazepines Phenobarbital generally preferred over phenytoin for second line therapy
