Acute Seizure Management

1. Acute Seizure Management Neurology Rotation Lecture Series Last Updated by Lindsay Pagano Summer 2013

2. Patient Presentation • EMS brings in a 6 year old female who has been seizing for 15 minutes • Previously healthy • Developed fever over the last several days and was sleepier then usual last night • Mom heard an odd noise and went in to check on her, and found her stiff and jerking in both arms and legs • EMS was called and gave ativan  seizure activity continued  repeat dosing  2 minutes later seizure stopped • Upon arrival she is febrile, difficult to arouse and has bilateral clonus with upgoing toes. Otherwise her exam is nonfocal. • Differential? Management?

3. What is it? Status Epilepticus • Definition: a seizure that lasts 30 minutes or longer OR a seizure cluster of similar duration in which the patient does not return to mental status baseline between seizures BUT • Definitions are changing…now being defined as > 5 minutes in adults, 10 minutes in children due to • High risk of lasting 30 minutes if it has already gone on 5 minutes • New models suggesting injury in less then 30 minutes • Regardless, treat after 5 minutes! Treatment delay is associated with slow response to treatment. • Why does it happen? • Complication of acute illness or injury (eg meningitis) • Uncontrolled or provoked epilepsy • Bimodal age distribution- increased incidence in < 1 year of age

4. How do I make it stop?! • Call Neurology! • In the meantime… • Diastat while getting an IV • Ativan 0.1 mg/kg IV up to 2 mg per dose…and repeat while awaiting below medications. Limiting factor is respiratory status, be ready to intubate! • Fosphenytoin 20/kg IV + order a free and total levels for 2 hours after the load • Keppra 20 mg/kg IV • Depakote 20 mg/kg IV (older than 2 years!) • Other things we’re thinking about FYI • Vimpat load • Versed drip • Pentobarb coma • Don’t forget to start maintenance 2 hours after the load! • Ask about missed home meds and give them

5. Back to the patient…what now? • Labs • Blood • Glucose • CMP (including calcium, magnesium) • CBC, BCx • ABG • AED levels • Urine: • UA, Ucx • UDS • CSF (after imaging): LP with opening pressure if possible (positioning?) • Basic studies: cell count, gram stain, culture, protein, glucose • Seasonally and age appropriate infectious labs (eg EV, HSV) • Imaging: CThead…what are we looking for?

6. EEG? • In this situation, evaluating for potential “burned out” status • Eg the medications didn’t stop the seizures, there is just no longer clinically obvious signs of seizure • Aka NCSE, nonconvulsive status epilepticus • Will also hook up for patients in whom we are planning to pursue burst suppression • Also used for ICP monitoring through the neurosurgeons

7. PREP question A 25 month old girl who has neurodevelopmental delay is brought to the ED via ambulance. She had appeared well the entire day, with no signs of illness, but at approximately 8 pm, her mother saw the child start to bend over and then become unconscious, her left arm began jerking, and her eyes rolled back. Her father quickly picked up the limp child, who had some continued jerking of her left arm. The jerking did not involve her legs or face. Her eyes were deviated to the left, her breathing was irregular, and she had some blueness around her lips. She then developed generalized stiffening with shaking of arms and legs that lasted 5 minutes. Two minutes later the spell recurred and continued for 20 minutes until EMS arrived and administered ativan. On PE, she has a temperature of 39.5⁰C and a right otitis media. Within 4 hours of administration of an antipyretic, she is afebrile and has returned to baseline status. The father states his brother had “fever seizures” in childhood. Of the following, the factor that increases this child’s risk of later epilepsy is: A. Family history of febrile seizures B. High temperature at seizure onset C. Neurodevelopmental abnormality D. Simple febrile seizures E. Young age of onset

8. C. Neurodevelopmental abnormality • Febrile seizures • Can be first sign of febrile illness • <6 years of age (would not expect first febrile seizure at the older end of this range) • Factors that make it complex: length of seizure (>15 minutes or multiple in 24 hours), focality • Workup if complex: EEG, imaging; in addition to relevant status workup in this case • Increased risk of epilepsy: FHx epilepsy, head trauma with LOC, neurodevelopmental delay, complex febrile seizure • Regarding the remaining choices: A. FHx of febrile seizures: increased risk for future febrile seizures B. high temp at seizure onset: not at increased risk for epilepsy D. simple febrile seizures: not at increased risk for epilepsy E. young age of onset: increased risk for future febrile seizures