The Management of Seizures and SE in the Emergency Department

1. The Management of Seizures and SE in the Emergency Department

2. Edward Sloan, MD, MPH, FACEP Associate Professor & Research Development Director Department of Emergency Medicine, University of Illinois at Chicago Chicago, IL (edsloan@uic.edu)

3. Global Objectives • Learn more about seizures • Increase awareness of Rx options • Enhance our ED management • Improve patient care & outcomes • Maximize staff & patient satisfaction • Be prepared for the EM board exam

4. Session Objectives • Provide seizure and SE overview • Summarize what Rx options exist • Discuss specific sub-groups • Outline ED Rx strategies

5. 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

6. Seizure Mechanism: • Sz = abnormal neuronal discharge with recruitment of otherwise normal neurons • Loss of GABA inhibition

7. Pathophysiology: • Glutamate toxic mediator • Necrosis occurs even if systemic problems are treated (HTN, fever, rhabdomyolysis, resp acidosis, hypoxia)

8. Pathophysiology: • Early compensation for increased CNS metabolic needs • Decompensation at 40-60 minutes, associated with tissue necrosis

9. Seizure Classification: • Generalized: both cerebral hemispheres • Partial: one cerebral hemisphere

10. Generalized Seizures : • Convulsive: tonic-clonic • Non-convulsive: absence

11. Generalized Seizures : • Primary generalized: starts as tonic-clonic seizure • Secondarily generalized: tonic-clonic seizure occurs as a consequence of a non-convulsive seizure

12. Partial Seizures : • Simple partial: no impaired consciousness • Complex partial: impaired consciousness

13. Specific Seizure Types : • Absence: Petit mal • Partial: Jacksonian, focal motor • Complex partial: temporal lobe, psychomotor

14. Status Epilepticus: • Sz > 5- 10 minutes = SE • Two sz without a lucid interval = SE (Assumes ongoing sz during coma)

15. SE Epidemiology: • Risk of SE greatest at extremes of age: pediatric and geriatric populations • SE: occurs in setting of acute insult, chronic epilepsy, or new onset seizure • 150,000 cases per year

16. SE Classification: • GCSE: Generalized convulsive SE, with tonic-clonic motor activity • Non-GCSE

17. Two Non-GCSE Types: • Non-convulsive SE • Absence SE • Complex-partial SE • Subtle SE • Late generalized convulsive SE • Coma, persistent ictal discharge • Very grave prognosis

18. AMS in Seizures: • Mental status should improve by 20-40 minutes • If pt comatose, then subtle SE is possible: EEG • Up to 20% of pts with coma still are in SE

19. Ongoing SE Effects: • Over 40-60 min, loss of metabolic compensation • With ongoing SE, systemic BP & CBF drop

20. SE Mortality: • SE mortality > 30% when sz longer than 60 minutes • Underlying sz etiology contributes to mortality

21. Subtle SE: • Mortality exceeds 50% • Often after hypoxic insult • Coma • Limited motor activity • Stop the sz, EEG confirm

22. General ED Management: • ABCs • Glucose, narcan, thiamine • Rapid sequential use of AEDs • Directed evaluation

23. Lab Evaluation: • Key lab abnormality: hypoglycemia, in up to 2% • Directed labs, including anti-epileptic drug levels

24. Lumbar Puncture: • Fever and CSF pleocytosis can occur in SE without meningitis • Use clinical criteria to determine LP need • AMS, immunocompromise, meningismus

25. Neuroimaging with CT: • CT useful with focal sz, change in sz type or frequency, co-morbidity • Req’d in new-onset sz • Non-contrast unless mass lesion suspected

26. Neuroimaging with MRI: • Useful with refractory sz • Complements plain CT • Can be done as outpt

27. EEG Monitoring: • EEG to rule out subtle SE • Prolonged coma, RSI, induced coma with propofol, pentobarbital • Obtain EEG in 120 minutes • Two-lead EEG in ED

28. AED loading: • Repeated seizures, high-risk population, significant SE risk • No need to determine level in ED after loading • Oral loading in low risk pts

29. 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)

30. New-Onset Sz: Recurrent Sz • 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 abn inc risk

31. ED Discharge: • Follow-up & EEG needed, esp if no AED prescribed • Driving documentation is critical. Know state law.

32. Pharmacotherapy of Seizures • Benzodiazepines • Phenytoins • Barbiturates • Other agents • valproate • propofol

33. General AED Concepts: • Most drugs are at least 80% effective in Rx seizures, SE • Have AEDs available in ED • Maximize infusion rate in SE • Use full mg/kg doses

34. Benzodiazepines: • GABA drug • Diazepam: short acting, limited AMS and protection • Lorazepam: prolonged AMS and protection • Pediatric sz: IV lorazepam limits respiratory compromise

35. Rectal Diazepam: • Diazepam rectal gel pre-packaged for rapid use • Dose 0.5 mg/kg, less respiratory depression seen than with IV use

36. Phenytoin: • Phenytoin: Na+ channel Rx • Load at 18 mg/kg, 1.5 doses • Infuse at 50 mg/min max • Use pump to prevent comp • Level 10-20 µg/mL

37. Fosphenytoin: • Fos: pro-drug, dose same • 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

38. IV Phenobarbital: • GABA-like, effective sz Rx • Limited availability • Infuse up to 50 mg/min • 20-30 mg/kg, 10 mg/kg doses • Level > 40 µg/mL

39. IV Valproate: • Likely GABA mechanism • Useful in peds, possibly SE • Rate up to 300 mg/min • 25-30 mg/kg, 3-6 mg/kg/min • Level > 100 µg/mL

40. Refractory SE: • SE refractory to benzos, phts, phenobarb, valproate • Propofol, pentobarb: useful third line agents • Midazolam infusion also useful • Respiratory depression, BP • Must control airway, get EEG

41. IV Propofol: • Likely GABA mechanism • Provides burst suppression • 2 mg/kg loading dose • Hypotension, resp depression, acidosis • Easily reversed

42. IV Pentobarbital: • Likely GABA mechanism • Provides burst suppression • 5 mg/kg loading dose • 25 mg/kg infusion rate • ICU monitoring required

43. ED Treatment Protocol: • Have AEDs easily available • Rapid sequential AED use • Maximize infusion rate • Maximize mg/kg dosing • Benzos, phenytoins, phenobarbital, valproate

44. No IV Access: • PR diazepam • IM midazolam • IM fosphenytoin • Buccal, intranasal midazolam • No IM phenytoin/phenobarbital

45. Special Populations • Drug and alcohol-related seizures • Acute CVA • Post-traumatic • Pregnancy • Pediatrics • Elderly • Psychogenic seizures

46. Drug-related Sz: • Stimulants, anti-depressants, theophylline and cocaine commonly can cause sz • Most sz treated with benzos • Phenytoin less useful

47. Drug-related Sz Rx: • INH: Blocks GABA production • Vit B6, pyridoxine • 5 gr IVP x 6, match ingestion gr • Theophylline: eliminate with hemodialysis, hemoperfusion • Tricyclics, cocaine: benzos,?? utility of other drugs

48. EtOH-related Seizures: • Occur 12 hrs p last drink • Lorazepam optimal Rx for sz • Lorazepam in DTs and sz prevention • Phenytoin ?? sz flurries, SE

49. Seizures in Acute CVA: • Seizures can occur in stroke • Consider prophylaxis with elderly, large hemorrhage, anterior CVA location

50. Post-traumatic Seizures: • High-risk populations exist • Early prophylaxis stops early sz, not late sz onset • Phenytoins, valproate