1
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Optimizing Seizure
and SE Patient
Management in the
Emergency
Department
Edward P. Sloan, MD, MPH
Professor
Department of Emergency Medicine
University of Illinois College of Medicine
Chicago, IL
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Disclosures
Attending Physician
Emergency Medicine
University of Illinois Hospital
Our Lady of the Resurrection Hospital
Chicago, IL
Edward P. Sloan, MD, MPH
• NovoNordisk,
NovoNordisk, King Pharmaceuticals,
UCB Pharma Advisory Boards
• Eisai Speakers’
Speakers’ Bureau
•
•
•
•
ACEP Clinical Policies Committee
ACEP Scientific Review Committee
Executive Board, FERNE
FERNE support by Abbott, Eisai, Pfizer,
UCB
Edward P. Sloan, MD, MPH
Board Chairman and President
FERNE
Chicago, IL
www.ferne.org
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
2
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Overview
Mission Statement
• Patients with neurological
emergencies deserve quality
emergency care.
• Quality scientific research.
• CaseCase-oriented, evidenceevidence-based medical
education on optimal acute neurological
care.
• Use of technology to break down space
and time barriers.
Edward P. Sloan, MD, MPH
• Advocacy.
www.ferne.org
Edward P. Sloan, MD, MPH
Today’s Agenda
• Present a clinical case
• Review seizure and SE clinical data
• Discuss ED management
• Provide fosphenytoin data
• Consider fosphenytoin use
• Examine the patient outcome
• Close with a bonus case
Edward P. Sloan, MD, MPH
Patient EMS Data
• 50?? yo male John Doe
• Generalized tonictonic-clonic seizure
• Chicago Fire Department
• Diazepam 5 mg IM, 15 mg IV
• Seizure continuous for 15 minutes +
• EMS to ED
• No change in status
Edward P. Sloan, MD, MPH
A Clinical Case
Edward P. Sloan, MD, MPH
Patient Clinical History
• Unknown meds
• Unknown medical history
• Hx Needs surgery next month ??
• EtOH ??
• Does not appear to be homeless
• Accucheck 119
Edward P. Sloan, MD, MPH
3
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
ED Presentation
• Facial and shoulder twitching R
• Pt with gurgling BS
• Nasopharyngeal airway
• No evidence of trauma or toxicity
• IV access in neck
• Seizure persists x minutes
Seizure/SE
Clinical Data
Edward P. Sloan, MD, MPH
Sz Epidemiology:
• Epilepsy seen in 1/150
people
• For each epilepsy pt, 1
ED visit every 4 years
• 1-2% of all ED visits
• Significant costs
Edward P. Sloan, MD, MPH
Seizure Mechanism:
• Sz = abnormal neuronal
discharge with recruitment
of otherwise normal
neurons
• Loss of GABA inhibition
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Seizures
Seizures
Seizure Classification:
Generalized Seizures:
• Generalized: both
• Convulsive: tonic-clonic
cerebral hemispheres
• Partial: one cerebral
hemisphere (localized)
Edward P. Sloan, MD, MPH
• Non-convulsive:
absence
Edward P. Sloan, MD, MPH
4
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Seizures
Seizures
Generalized Seizures:
Partial Seizures:
• Primary generalized: starts as
tonic-clonic sz
• Secondarily generalized:
tonic-clonic sz develops from
a non-convulsive partial sz, ie
aura (common)
Edward P. Sloan, MD, MPH
• Simple partial: no
impaired consciousness
• Complex partial:
impaired consciousness
Edward P. Sloan, MD, MPH
Seizures
Seizures
Specific Seizure Types:
Recurrent Seizure Risk
• Absence: Petit mal
• Partial: Jacksonian, focal
motor
• Complex partial: temporal
lobe, psychomotor
Edward P. Sloan, MD, MPH
• 51% recurrence risk
• 75% of recurrent sz occur
within 2 years of first sz
• Only a small % of pts will
seize within 24 h
• Partial sz, CNS abnormality
Edward P. Sloan, MD, MPH
Status Epilepticus
Status Epilepticus:
• Sz > 5- 10 minutes
• Two sz without a lucid
interval (Assumes
ongoing sz during coma)
Edward P. Sloan, MD, MPH
SE Epidemiology:
• Risk of SE: greatest at age
extremes (pediatric and
geriatric populations)
• SE: occurs in setting of new
onset sz, acute insult, or
chronic epilepsy
• 150,000 cases per year
Edward P. Sloan, MD, MPH
5
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Status Epilepticus
Status Epilepticus
SE Classification:
Two Non-GCSE Types:
• GCSE: (Generalized
convulsive SE) with tonicclonic motor activity
• Non-GCSE
• NonNon-convulsive SE
• Absence SE
• ComplexComplex-partial SE
• Subtle SE
• Late generalized convulsive SE
• Coma, persistent ictal
discharge
• Very grave prognosis
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Seizures/SE
Seizures/SE
Systemic Effects:
Pathophysiology:
• Hypertension (early)
• Hypotension (later)
• 49% will have temp > 100.5 F°
• Lactic acidosis
• Hypercarbia
Edward P. Sloan, MD, MPH
• Glutamate toxic mediator
• Necrosis occurs even if
systemic problems are
treated (HTN, fever,
rhabdomyolysis, resp
acidosis, hypoxia)
Edward P. Sloan, MD, MPH
Seizures/SE
Seizures/SE
Pathophysiology:
AMS in Seizures:
• Early compensation for
increased CNS metabolic
needs
• Decompensation at 40-60
minutes, associated with
tissue necrosis
Edward P. Sloan, MD, MPH
• Mental status should
improve by 20-40 minutes
• If pt comatose, subtle SE is
possible: EEG
• Up to 20% of pts in coma
are still in SE
Edward P. Sloan, MD, MPH
6
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Seizures/SE
Status Epilepticus
Ongoing SE Effects:
SE Mortality:
• Over 40-60 min, loss of
metabolic compensation
• With ongoing SE, systemic
BP & CBF drop
• SE mortality > 30% when sz
longer than 60 minutes
• Underlying sz etiology
contributes to mortality
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Status Epilepticus
Status Epilepticus
Subtle SE:
Refractory SE:
• Mortality exceeds 50%
• Often after hypoxic insult
• Coma
• Limited motor activity
• Stop the sz, EEG confirm
Edward P. Sloan, MD, MPH
• No response to first-line
drugs (Benzos, phenytoins)
• Significant CNS disorders
• 6-9% of all SE cases
• 20-30% mortality
Edward P. Sloan, MD, MPH
ED Management
General ED Management:
• ABCs
• Glucose, narcan, thiamine
• Rapid sequential use of
AEDs
• Directed evaluation
Edward P. Sloan, MD, MPH
Lab Evaluation:
• Key lab abnormality:
hypoglycemia, in up to 2%
• Directed labs, including
anti-epileptic drug levels
Edward P. Sloan, MD, MPH
7
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
ED Management
ED Management
Lumbar Puncture:
CT Neuroimaging:
• Fever and CSF pleocytosis
can occur in SE without
meningitis
• Use clinical criteria to
determine LP need
• AMS, immunocompromise,
meningismus
Edward P. Sloan, MD, MPH
• Req’d in new-onset sz
• Useful with focal sz, change
in sz type or frequency, comorbidity
• Non-contrast unless mass
lesion suspected
Edward P. Sloan, MD, MPH
New Onset Sz in Pregnancy
•
•
•
•
•
•
•
32 year old Hispanic female
23 weeks pregnant
G3P2 two live births, no complications
New onset seizure at 530 am in bed
Generalized tonic-clonic seizure
Brief, self-limited, no Rx required
EMS to the ED, no seizure recurrence
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
New Onset Sz in Pregnancy
Focal hemorrhage
Edward P. Sloan, MD, MPH
– Tertiary center diagnosis: cavernoma
– Started on an anti-epileptic drug
– No immediate need for operative
intervention
– Will follow as pregnancy progresses
Edward P. Sloan, MD, MPH
8
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
ED Management
ED Management
MRI Neuroimaging:
EEG Monitoring:
• Useful with refractory sz
• Complements plain CT
• Can be done as outpatient
Edward P. Sloan, MD, MPH
• Use to rule out subtle SE
• Two-lead EEG in ED, within
120 minutes
• In RSI, prolonged coma,
propofol or pentobarbital
induced coma
Edward P. Sloan, MD, MPH
ED Management
ED Management
AED loading:
SE Rx Timeline:
• Repeated seizures, high-risk
population, significant SE
risk
• No need to determine level in
ED after loading
• Oral loading in low risk pts
• 0-30 min: ABCs, benzos
• 30-60 min: Phenytoins
• 60-90 min: Levetiracetam,
phenobarbital, valproate
• 90-120 min: Midazolam, propofol
CT, EEG, ICU/OR
Edward P. Sloan, MD, MPH
Hospital Admission:
• Repeated sz, high-risk pt,
significant SE risk
• Esp if no AED loading
• New-onset seizure:
admission is preferred
(complete w/u, observe)
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
ED Discharge:
• Follow-up & EEG needed,
esp if no AED prescribed
• Driving documentation is
critical. Know state law.
Edward P. Sloan, MD, MPH
9
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Seizure Pharmacotherapy
ED Anti-epileptic
Drug (AED) Use
Edward P. Sloan, MD, MPH
•
•
•
•
Benzodiazepines
Phenytoins
Barbiturates
Other agents
–levetiracetam
–propofol
–valproate
Edward P. Sloan, MD, MPH
Pharmacotherapy
Pharmacotherapy
Clinical Setting:
General AED Concepts:
• Three seizure settings
• SelfSelf-limited seizure, load req’
req’d
• Flurry of seizures, atat-risk for SE
• Status epilepticus
• Provides framework for
discussion
Edward P. Sloan, MD, MPH
• Most drugs are at least 80%
effective in Rx seizures, SE
• Have AEDs available in ED
• Use full mg/kg doses
• Maximize infusion rates in SE
Edward P. Sloan, MD, MPH
Pharmacotherapy
Pharmacotherapy
Benzodiazepines:
Rectal Diazepam:
• GABA inhibition
• Diazepam: short acting, limited
AMS and protection (intubation
more common)
• Lorazepam: prolonged AMS and
protection
• Pediatric sz: IV lorazepam limits
respiratory compromise
• Diazepam rectal gel prepackaged for rapid use
• Dose 0.5 mg/kg, less
respiratory depression seen
than with IV use
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
10
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Pharmacotherapy
Pharmacotherapy
Phenytoin:
Oral Phenytoin:
• 18mg/kg oral load
• 64% reach 10mg/mL levels by
8 hrs (therapeutic)
• Delayed absorption due to
large loading, or drug prep
• Stabilize memb Na+ channels,
regulate Ca+ + channels
• For generalized sz, and SE
• Constant infusion over IVP
• Use pump to prevent comp
• Therapeutic at 10-20 µg/mL
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Pharmacotherapy
Adverse Events Following
IV CEREBYX® or IV Phenytoin
100
Edward P. Sloan, MD, MPH
CEREBYX at 150 mg PE/min (n=90)
IV Phenytoin at 50 mg/min (n=22)
59.1
Pruritis unique to fospht
48.9
31.1
27.3
27.3
20.0
20
18.2
11.1
ce
4.5
le
n
da
ch
e
he
s
ia
iti
s
es
t
Pr
ur
Pa
r
ne
ss
D
iz
zi
N
ys
ta
gm
us
0
0.0
2.2
So
m
no
4.4
H
ea
4.5
7.7
9.1
n
44.4
40
en
sio
60
ax
ia
Subjects (%)
80
At
• Pro-drug, dose same as pht
• Infuse at 150 mg/min in SE
• Can be given IM up to 20cc
• Level 10-20 µg/mL
• Delayed level: 2h IV, 4 h IM
Hy
po
t
Fosphenytoin:
Refer to full Prescribing Information for the full adverse events incidence.
Cerebyx® (fosphenytoin sodium injection) [package insert]. Morris Plains, NJ: WarnerLambert; 2002.
Pharmacotherapy
Fosphenytoin
Fosphenytoin:
Rapid Infusion in “At-risk” Pts:
• Cost-effective in 6 settings
–Rapid infusion in “at-risk pts”
–Rapid infusion in SE
–High-risk IV access
–No IV access (IM)
–No cardiac monitoring (IM)
–Poor patient compliance
Edward P. Sloan, MD, MPH
•
•
•
•
•
Infuse at 100100-150 mg/min
Load in 1010-20 minutes
Therapeutic after diazepam
Limits lorazepam use
Lowers monitoring need
Edward P. Sloan, MD, MPH
11
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Fosphenytoin
CEREBYX® and IV Phenytoin:
Comparable Pharmacokinetic Profiles
•
•
•
•
•
Mean Plasma-Free Phenytoin
Concentration (µg/mL)
Rapid Infusion in SE:
Infuse at 150 mg/min in SE
One gram infusion in 7 min
Full 20 mg/kg load in 10 min
30 mg/kg load in 15 min
Fos resuscitation, next AED
Edward P. Sloan, MD, MPH
3
N = 12
2
Similar time to therapeutic
free phenytoin level
1
CEREBYX at 150 mg PE/min
IV Phenytoin at 50 mg/min
0
0
30
60
90
120
Time After Start of Infusion (min)
Cerebyx® (fosphenytoin sodium injection) [package insert]. Morris Plains, NJ: WarnerLambert; 2002.
Always consult full Prescribing Information in package insert.
ED Management
Fosphenytoin
SE Rx Timeline:
High-risk IV Access
0-30 min: ABCs, benzos
• 3030-60 min: Phenytoins
• 6060-90 min: Levetiracetam,
phenobarbital, valproate
• 9090-120 min: Midazolam,
Midazolam, propofol
CT, EEG, ICU/OR
•
Edward P. Sloan, MD, MPH
•
•
•
•
Murphy’
Murphy’s Law
Extravasations will occur
LongLong-term complications go
undetected by ED physicians
Consider your preferences
Edward P. Sloan, MD, MPH
Fosphenytoin
Fosphenytoin
No IV Access
No IV Access
• IVDA in locklock-up, prevent SE
• Must achieve adequate level
• Avoid ED problems
• ED nurse time, agitation
• Adverse exposure risk
• Prolonged ED throughput time
Edward P. Sloan, MD, MPH
• Out of hospital setting
• Protocol in EMS setting
• Long transports in rural EMS
• Specialty care providers
• Nursing homes
• Private MD offices
Edward P. Sloan, MD, MPH
12
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Pain Scores at Injection Site
Following IM Administration of
CEREBYX® or Saline
None
Mild
Moderate
95.8
87.5
60
100
Severe
50
83.3
Patients (%)
Subjects (%)
100
IM CEREBYX® Administered
at a Single and Multiple Sites
54.2
50
12.5
25.0
16.7
4.2
16.7
4.2
CEREBYX
Saline
CEREBYX
Immediately
Post-Injection
(N = 13)
(N = 11) (N = 12)
30
20
(N = 3)
(N = 4)
(N = 3)
(N = 3)
0
(10 mg PE/kg)
(10 mg PE/kg)
14 pts, 15+cc IM injection
(N = 11)
40
10
0
Saline
Single Sites
Multiple Sites
≤10
1-Hour
Follow-up
>10-15
>15-20
>20
Volumes Administered (mL)
IM fos pain similar to IM saline
Adapted with permission from Pryor FM et al. Epilepsia. 2001;42:245-250.
Always consult full Prescribing Information in package insert.
Ramsay RE et al. Epilepsy Res. 1997;28:181-187.
Always consult full Prescribing Information in package insert.
Fosphenytoin
Fosphenytoin
No Cardiac Monitoring
Poor Patient Compliance
• ED overcrowding
• High acuity, stretched resources
• Utilize IM loading
• No need for monitoring
• Less risk of hypotension
• No unplanned rapid infusion
• More disposition options
Edward P. Sloan, MD, MPH
•
•
•
•
• Pt refuses to stay for infusion
• About to enter high risk setting
• Utilize IM loading
• Rapidly therapeutic
• Half load IM, half PO
• Reduced SE risk
• Rapid dispo,
dispo, not AMA
Edward P. Sloan, MD, MPH
Fosphenytoin
Fosphenytoin
Use in Elderly Patients
Use in Pediatric Patients
Caution with hypotension when
rapidly infused
CVA neuroprotection study
Related to phenytoin moiety
Rate related, slow infusion
Edward P. Sloan, MD, MPH
•
•
•
•
•
Used in infants and children
Reasonable to use in all ages
Safety not an issue
IM and IV use both possible
Neonate indication and use: in
consultation with peds neurology
Edward P. Sloan, MD, MPH
13
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Pharmacotherapy
Pharmacotherapy
IV Levetiracetam:
IV Phenobarbital:
• Second generation AED
• Oral and IV bioequivalent
• Adjunct therapy
• No therapeutic level defined
• 1500 to 3000 mg infusion
• Few adverse effects
Edward P. Sloan, MD, MPH
•
•
•
•
•
•
• GABA-inhib, effective SE Rx
• Infuse up to 50 mg/min
• 20-30 mg/kg, 10 mg/kg doses
• Therapeutic > 40 µg/mL
• Respiratory depression
• Hypotension
Edward P. Sloan, MD, MPH
Pharmacotherapy
Pharmacotherapy
IV Valproate:
IV Lidocaine:
Likely GABA mechanism
Useful in peds, possibly SE
Rate up to 300 mg/min
25-30 mg/kg, 3-6 mg/kg/min
Therapeutic > 100 µg/mL
Per mg/kg load, level up 5 µg/mL
Edward P. Sloan, MD, MPH
• Third-line, stabilizes
membrane Na + /K + pump
• Decreased neuron
excitability, refractory GCSE
• 3 mg/kg
• Not effective relative to others
Edward P. Sloan, MD, MPH
Pharmacotherapy
Pharmacotherapy
IV Midazolam Infusion:
IV Propofol Infusion:
• GABA mechanism
• Equal to diazepam infusion
• Greater breakthru sz rates
• Less hypotension
–vs. propofol, pentobarb
Edward P. Sloan, MD, MPH
• Likely GABA mechanism
• Provides burst suppression
• 2 mg/kg loading dose
• Hypotension, acidosis,
hypoventilation
• Rapid onset, easily reversed
Edward P. Sloan, MD, MPH
14
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Pharmacotherapy
Pharmacotherapy
IV Pentobarbital:
ED Treatment Protocol:
• Likely GABA mechanism
• Provides burst suppression
• 5 mg/kg loading dose
• 25 mg/kg infusion rate
• ICU monitoring required
Edward P. Sloan, MD, MPH
• Have AEDs easily available
• Rapid sequential AED use
• Maximize infusion rate
• Maximize mg/kg dosing
• Benzos, phenytoins, other
bolus AEDs, continuous AEDs
Edward P. Sloan, MD, MPH
Pharmacotherapy
No IV Access:
• PR diazepam
• IM midazolam
• IM fosphenytoin
• Buccal, intranasal midazolam
• No IM phenytoin/phenobarbital
Edward P. Sloan, MD, MPH
Evidence Based Guidelines
• Define the clinical question
– Focused questions best
– Outcome measure must be
determined
• Grade the strength of evidence
• Incorporate practice patterns,
available expertise, resources and
risk/benefit
Edward P. Sloan, MD, MPH
ACEP Seizure/SE
Clinical Policy
Edward P. Sloan, MD, MPH
ACEP Clinical Policies
• Identify questions of clinical
importance to ED practitioners
• Analyze the quality of data
available related to disease state
• Differentiate anecdotal
experience from practice
supported by evidence
Edward P. Sloan, MD, MPH
15
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Evidence Strength
• Strength (Class) of evidence
– I: Randomized, double blind interventional
studies for therapeutic effectiveness;
prospective cohort for diagnostic testing or
prognosis
– II: Retrospective cohorts, case control studies,
cross-sectional studies
– III: Observational reports; consensus reports
• Evidence strength downgraded if flawed
methodologically
Edward P. Sloan, MD, MPH
Recommendation Strength
• Strength of recommendations:
– A (Standard): High degree of
certainty based on Class I studies
– B (Guideline): Moderate clinical
certainty based on Class II studies
– C (Option): Inconclusive certainty
based on Class III evidence,
consensus
Edward P. Sloan, MD, MPH
New Onset Sz: Lab Testing
What lab tests are indicated in the
otherwise healthy adult patient
with a new onset seizure who has
returned to a baseline normal
neurological status?
(Outcome measure: abnormal lab that
changes management)
Edward P. Sloan, MD, MPH
New Onset Sz: Lab Testing
• Level B recommendations:
– Determine a serum glucose and
sodium on patients with a first time
seizure with no co-morbidities who
have returned to their baseline
– Obtain a pregnancy test in women of
child bearing age
– Perform a LP after a head CT either
in the ED or after admission on
patients who are immunocompromised
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
New Onset Sz: Neuroimaging
Which new onset seizure patients
who have returned to a normal
baseline require neuroimaging
in the ED?
(Outcome measure: abnormal CT)
Edward P. Sloan, MD, MPH
16
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
New Onset Sz: Neuroimaging
New Onset Sz: Dispo/AED Use
• Level B recommendations:
–When feasible, perform a head
CT of the brain in the ED on
patients with a first time seizure
–Deferred outpatient
neuroimaging may be utilized
when reliable follow-up is
available
Which new onset seizure patients who
have returned to normal baseline
need to be admitted to the hospital
and / or started on an AED?
Edward P. Sloan, MD, MPH
New Onset Sz: Dispo/AED Use
• Level C recommendations:
– Patients with a normal neurological
examination can be discharged from
the ED with outpatient follow-up
– Patients with a normal neurological
examination and no co-morbidities
and no know structural brain disease
do not need to be started on an antiepileptic drug in the ED
Edward P. Sloan, MD, MPH
Sz/SE: Phenytoin Loading
–Level C recommendation:
−Administer an intravenous or
oral loading dose of phenytoin
or intravenous or
intramuscular fosphenytoin,
and restart daily oral
maintenance dosing.
Edward P. Sloan, MD, MPH
(Outcome measure: short term
morbidity or mortality)
Edward P. Sloan, MD, MPH
Sz/SE: Phenytoin Loading
What are effective phenytoin dosing
strategies for preventing seizure
recurrence in patients who present
to the ED with a sub-therapeutic
serum phenytoin level?
(Outcome measure: short term
seizure recurrence)
Edward P. Sloan, MD, MPH
Sz/SE SE Therapeutics
What agent(s) should be
administered to a patient in status
who continues to seize despite a
loading dose of a benzodiazepine
and a phenytoin?
(Outcome measure: cessation of
motor activity)
Edward P. Sloan, MD, MPH
17
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
Sz/SE SE Therapeutics
Sz/SE: EEG Monitoring
• Level C recommendation:
–Administer one of the following
agents intravenously: “highdose phenytoin,” phenobarbital,
valproic acid, midazolam
infusion, pentobarbital infusion,
or propofol infusion.
When should an EEG be
performed in the ED?
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Sz/SE: EEG Monitoring
ACEP Summary
• Level C recommendation:
–Consider an emergent EEG for
patients suspected of being in nonconvulsive SE or in subtle
convulsive SE, for patients who
have received a long-acting
paralytic, or for patients who are in
a drug-induced coma.
• Evidence based clinical policies are useful
tools in clinical decision making
• Policy does not create a “standard of care”
• Provides a foundation for clinical practice at
a national level
• The current literature does not support the
creation of any “level A” recommendations
– 2 of the 6 clinical questions have sufficient
evidence to support “level B”
recommendations
– 4 of the 6 recs are “level C”
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
ED Patient Management
ED Patient Outcome
Edward P. Sloan, MD, MPH
•
•
•
•
•
•
•
•
Lorazepam 2 mg IVP x 5 over 10 minutes
Persistent facial and R shoulder activity
AMS: generalized seizure continues
Fosphenytoin 1 gram PE over 10 min
Fosphenytoin 1 gram PE over 10 min
Seizure ended, pt remained obtunded
Intubation immediately followed
Lidocaine, sux,
sux, rocuronium
Edward P. Sloan, MD, MPH
18
ED Management of Seizure and Status Epilepticus Patients
Edward P. Sloan, MD, MPH, FACEP
ED Diagnostic Evaluation
Family Arrives, Pt History
•
•
•
•
•
•
•
•
•
•
•
•
NonNon-contrast CT: Prior strokes, atrophy
Metabolic tests normal
Toxicology screening negative
Phenytoin level cancelled
Diagnoses:
• AMS
• Status Epilepticus
• Respiratory Failure
Pt with history refractory seizures
Hx carotid artery occlusion R
Due for carotid endarterectomy
Phenobarbital & dilantin, compliant
Prior history of SE treated at UIC
No medic alert bracelet
No recent illness, trauma, EtOH
Edward P. Sloan, MD, MPH
Patient Outcome
•
•
•
•
•
EEG in ED, within 150 minutes
Neuro consultation, no subtle SE
Admit to Neuro ICU
Repeated paralytic dosing
Final disposition for carotid Rx
Edward P. Sloan, MD, MPH
Conclusions
• Effective ED seizure patient Rx is
critical to good long-term outcome
• Parenteral ED AED use can be easily
implemented for effectiveness
• Must understand principles that govern
ED AED use and priorities of those that
provide long-term epilepsy Rx
• Those principles are fortunately simple
and straightforward
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Recommendations
• Be able to identify the seizure type and
optimal patient therapies based on
etiology, demographics, and risk/benefit
• Establish seizure and SE protocol
• Understand fully the optimal use of all
parenteral and 2nd generation AEDs
• Stop the acute seizure & prevent SE
• Wisely prescribe so that follow-up
epilepsy management can be optimized
Edward P. Sloan, MD, MPH
Questions?
www.FERNE.org
edsloan@uic.edu
312 413 7490
ferne_2007_stcatherine_sloan_seizures_final
2/14/2007 7:46 AM
Edward P. Sloan, MD, MPH