Emdocs Dr Anna Pickens Emin5 Makes the List Again
Instance
EMS arrives with a 39 year old adult female who was found down in a generalized tonic clonic seizure. The seizure has been ongoing for at least 12 minutes now, so this is status epilepticus. No information is bachelor well-nigh her past history. The paramedics were unable to start an Iv, only did administrate a dose of IM midazolam…
Please Note: A new version of this post was created in 2019. The new post can be establish here.
My approach
Different simple seizures, which volition by and large resolve without whatever intervention and crave clinical constraint to avoid overtreatment, status epilepticus (with generalized tonic clonic seizures) is a medical emergency that requires immediate management.
The first words out of your mouth should probably be, "what's the carbohydrate?" Not only is it embarrassing to miss hypoglycemia, it is an easily identifiable and hands treatable etiology of status epilepticus. If for some reason you are unable to get a level, just go ahead and treat empirically with D50W.
What do I practice nigh the airway and animate?
The beginning priority should be terminating seizure activeness, because that will by and large solve whatsoever airway and breathing issues. You don't demand to ventilate the patient immediately, but oxygen is important because the patient is burning through it very quickly. I place nasal trumpets bilaterally and apply a non-rebreather facemask in an attempt to provide some apneic oxygenation.
The management of status epilepticus will require venous access. If an Iv is not rapidly bachelor, I place an IO. (Initial doses of antiepileptics can be given without an Four, for case IM or IN midazolam, merely further treatment will crave vascular access.)
Start a benzodiazepine
It really doesn't matter which 1 you pick – they all work. Usually this first dose will accept already been given before the patient arrives. If an IV has non been started, I will also often use either an IM or intranasal dose before placing an IO.
| Benzo | Pediatric Dose | Usual dose | ||
| Lorazepam 4 | 0.1mg/kg | 4-8mg | ||
| Midazolam IV | 0.1mg/kg | 5-10mg | ||
| Midazolam IN | 0.2mg/kg | |||
| Midazolam IM | 0.2mg/kg | v-10mg | ||
| Diazepam 4 | 0.2mg/kg | 10mg |
More benzodiazepine
If there is no response iv minutes afterward the get-go benzo, I repeat the dose.
Special Case: Eclampsia
Eclampsia must exist considered in any female of childbearing historic period before moving on to second-line medications. Women in their third trimester should be relatively obvious, but eclampsia tin can occur up to viii weeks postpartum, so you may need to be treated empirically. Requitem agnesium 4 grams IV.
Nigh published algorithms will have with phenytoin or fosphenytoin as the 2nd-line amanuensis. I don't like this option in the actively seizing patient because it just takes as well long (at least 20 minutes). Also, phenytoin is by and large contraindicated for toxicologic seizures and I rarely have enough information in the first 15 minutes to exclude overdose. If a patient doesn't respond to a few good doses of a benzo, I am going to be intubating, and therefore I volition exist starting a general anesthetic. I will go the phenytoin started equally soon equally I can after the first dose of benzo doesn't piece of work, merely I empathize that it isn't going to work for 20-thirty minutes, so it is really my third line agent. My second line drug is p ropofol 1.five-2mg/kg IV and then xx-200mcg/kg/min. If there are contraindications, primarily any business about cardiac reserve or hemodynamic stability, ketamine 2 mg/kg IV is a skillful alternative.
Intubation
After 2 doses of benzodiazepine don't work, I am going to intubate. My second line anti-epileptic (propofol) is also my induction agent. First laissez passer success is ever important, simply especially so after prolonged seizures, with loftier oxygen demand and very limited ability to pre-oxygenate. My go to volition be standard RSI, with apneic oxygenation, just I anticipate I may need to gently bag the patient during the apneic menstruum.
Choice of paralytic
Succinylcholine could cause hyperkalemia if seizures take been extremely prolonged and rhabdomyolysis has already adult or if in that location is an underlying neurologic disorder. However, the prolonged paralysis of rocuronium increases the risk of developing nonconvulsive status epilepticus. In the platonic situation, nonconvulsive status is quickly and easily diagnosed by EEG, but unfortunately that is just not viable for many of us. I will generally stick with succinylcholine, unless their is a clear contraindication.
Searching for reversible causes
The search for a reversible cause of seizures is the most important task between doses of benzos and after intubation.
- Infectious
- Virtually all patients in status are going to be hot, so infectious causes volition come to mind. Empiric antibiotics and acyclovir should probably be given early to anybody.
- Eclampsia
- In case it was overlooked in the initial few minutes, all women of childbearing historic period must exist considered for the diagnosis of eclampsia.
- Isoniazid toxicity
- Depending on your population (urban hospitals or many countries that aren't Canada), you might want to care for empirically for isoniazid toxicity. The antidote is pyridoxine (i gram of pyridoxine for every gram of isoniazid (to a max of 5 grams) in a known overdose, or just 5 grams empirically)
- Hyponatremia
- NaCl 3% 2ml/kg (150 in 70 kg pt); may repeat in 10 minutes if needed
- Sodium channel blocker toxicity
- Sodium bicarbonate Iv (100mEq or 2mEq/kg)
- Booze withdrawal
- You are already treating this, only will need a lot more benzos
- Cyanide
- Hydroxocobalamin 70mg/kg (5 gram standard dose)
- Or the cyanide antitoxin kit (amyl nitrate, sodium nitrite, and sodium htoisulfate)
Concluding options
- Barbituates: Some people might use these in place of propofol higher in this algorithm. That is reasonable. I like propofol because its a drug I use every single shift. (Phenobarbital 20mg/kg loading dose over 15 min)
- Levetiracetam: If the starting time anti-epileptic doesn't work, you are unlikely to go any do good from adding a second. All the same, I don't know any neurologists who tin can walk by a seizure patient without starting them on levetiracetam these days. A loading dose of i gram IV is reasonable
- Ketamine: Although not backed by any testify in condition epilpticus, the apply of ketamine (an NMDA receptor adversary) makes sense in conjunction with the overflowing of the GABA agonists yous have already tried
- Inhalational anesthetics: As a concluding effort, inhalational anesthetics have been described in cases of condition epilepticus
Notes
Although older definitions of status epilepticus focused on seizures lasting more 30 minutes, a more practical definition is whatever individual seizure lasting more than 5 minutes or ii seizures without full recovery of consciousness. From an emergency department standpoint, it a patient is still seizing by the time EMA arrives, it is status.
There are many theoretical reasons that one benzo might be called over another, but in caput to head trials they take e'er come identical. The just note I would brand about specific agents is that diazepam seems to have a higher rate of recurrent seizures (up to 50% in the first 2 hours) if another antiepileptic is not given. If diazepam was successfully used to finish the seizure, I would probably get-go phenytoin.
Controversial airway aside
Might a allaying only endeavor at intubation make sense in status? In hospitals like mine with no access to EEG, non-convulsive condition after paralytics will be very challenging to manage. In a seizing patient, the combination of convulsions and trismus will probably make paralytics necessary for a rubber intubation attempt. Withal, the consecration agents that we use are besides anti-epileptics that might terminate the seizure, potentially obviating the demand for paralysis.
I take no science or fifty-fifty feel to support this arroyo, just I wonder if it makes sense:
- Give a generous dose of a sedation agent, such every bit propofol 2mg/kg
- A paralytic is drawn up, but it is not given with the sedative
- At 60 seconds, make a single attempt at intubation without paralysis
- If the tube cannot exist easily passed, or at that place are ongoing convulsions or trismus that prevent laryngoscopy, the paralytic is pushed, the patient is briefly bagged as needed, and the usual intubation algorithm is resumed
Other FOAMed Resources
Seizures on EM Basic
Status epilepticus: When the seizure doesn't finish on Intensive Care Network
Status Epilepticus Critical Intendance Compendium on Life in the Fastlane
Rapid Sequence Termination of status epilepticus on PulmCrit
EMCrit #155: Status epilepticus with Tom Bleck
The SMACC Chicago talk by Tom Bleck – CONTROVERSIES IN THE ACUTE MANAGEMENT OF Status EPILEPTICUS – covers a lot of the testify on which I base my algorithm
Why we do what we do: Benzodiazepines as commencement line therapy for condition epilepticus on PEMBlog
Seizure answers on EM Lyceum
Special seizures on EMin5:
References
Shearer P, Riviello J. Generalized convulsive status epilepticus in adults and children: handling guidelines and protocols. Emergency medicine clinics of North America. 29(1):51-64. 2011. PMID: 21109102
Sharma AN, Hoffman RJ. Toxin-related seizures. Emergency medicine clinics of Northward America. 29(1):125-39. 2011. PMID: 21109109
Lung DD, Catlett CL, Tintinalli JE. Affiliate 165. Seizures and Status Epilepticus in Adults. In: Tintinalli JE et al. eds. Tintinalli'due south Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Loma; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381644
Millikan D, Rice B, Silbergleit R. Emergency treatment of status epilepticus: current thinking. Emergency medicine clinics of North America. 27(ane):101-13, ix. 2009. PMID: 19218022
McMullan J, Duvivier E and Pollack C. Affiliate 102. Seizure Disorders. In: Marx JA et al. eds. Rosen's Emergency Medicine, 8e. Philadelphia: Elsevier Saunders; 2014.
Morgenstern, J. Management of condition epilepticus in the emergency department, First10EM, November 16, 2015. Available at:
https://doi.org/ten.51684/FIRS.927
Source: https://first10em.com/status-epilepticus/
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