Emergency Management of Seizures

1. Emergency Management of Seizures Deb Funk, M.D., NREMT-P Medical Director; Albany MedFLIGHT Saratoga EMS

2. Goals • Review definitions, classifications and pathophysiology • Discuss several patient scenarios • Assessment • Management • Discuss current pharmacologic techniques for management of ongoing seizures

3. Definitions • Seizure: episodic abnormal neurologic functioning caused by abnormally excessive activation of neurons • Epilepsy: a clinical condition characterized by recurrent seizures • status epilepticus: >30min seizure or >2 seizures w/o recovery

4. Epidemiology • 6-10% of US population will have at least 1 afebrile seizure during their lifetime • 1-2% have recurrent seizures • 100,000 new cases in US annually • Adult first time seizures represent 1% of all ED visits • incidence highest <20 and >60yrs • Male > female

5. Classification • primary/secondary • Primary do not have obvious source • Secondary occur as a result of many types of injuries/illnesses • generalized/focal • generalized involves abnl neuron activity in both cerebral hemispheres • tonic/clonic, absence, myoclonic • focal involve 1 hemisphere • simple partial, complex partial, secondarily generalized

6. Generalized: Tonic-Clonic Seizure • most common • vague prodromal symptoms • tonic phase • trunk flexion-->extension, eyes deviate up, mydriasis, vocalization • clonic phase • tonic contractions alternate with muscle atonia

7. Generalized: Tonic-Clonic cont’d • loss of consciousness and autonomic alterations during both phases • any focality noted during or after seizure may point to the origin • hypocarbia (resp alkalosis/lactic acidosis), transient hyperglycemia, CSF pleocytosis, elevated serum prolactin • post ictal phase • coma-->confusional state-->lethargy, myalgia, headache

8. Pathophysiology of Seizures • in general not well understood • neuronal recruitment is a common theory and has been demonstrated in some studies • propagation of abnormal electrical impulse to adjacent neurons along variable paths • the pathway involved usually determines the type of seizure seen • generalized sz: focus deep and midline, involving the RAS • focal sz: more limited focus of activity/does not cross midline

9. Pathophysiology cont’d • typically self limited • bursts of electrical discharges from the focus terminate • reflex inhibition/neuronal exhaustion/alteration of neurotransmitter balance.

10. Case 1 • 2 yr old previously healthy boy given Tylenol for tactile temp by Mom. Twenty min later had “shaking episode.” • What more do you need to know? • What do you look for on exam? • What is your assessment and plan?

11. Febrile Seizure: Definitions • generalized seizure occurring during a sudden rise in temp in absence of intracranial infection or other defined etiology • Simple: single event lasting less than 15 min (90%) • Complex: exceed 15 min, occur more than once in 24hr period, or show focal motor manifestations (higher rate of epilepsy)

12. Febrile Seizure: Statistics • 2-5% of children • most common pediatric seizure • 30% will have a single recurrence (1/2 of these will have multiple) • age of onset 6mos-5yrs (peak 18-24 mos) • family history conveys 2-3 times the general population risk • 2-9% develop afebrile seizures

13. Febrile Seizures: Assessment • History • PMH/AMPLE (immunization hx) • Recent illness • Details of event • Physical Exam • MS/ABC’s • Detailed neuro exam • Search for source of fever (in ED)

14. Febrile Seizure: management • ABCs and monitor VS • Check blood glucose • abort seizure if ongoing (benzodiazepine) • IV/IM/PR administration • Cooling measures • Transport to appropriate hospital Reference REMO Protocol P-10 Pediatric Seizures

15. Case 2 • 42 y/o WM reportedly had a seizure at a Phish concert. Friends think he takes Dilantin. • What more do you need to know? • What do you look for on exam? • What is your assessment and plan?

16. Epilepsy: Considerations • multiple different epilepsy syndromes • breakthrough vs noncompliance • provoking factors

17. Epilepsy: statistics • Affects 1.5-2.5 million people in US • 30-40% patients with epilepsy continue to have breakthrough seizures despite appropriate medical management

18. Epilepsy: assessment • History • determine: • intercurrent illness/trauma • Sleep deprivation • drug or etoh use • drug drug interactions • med compliance • recent change in dosing regimen • change in seizure pattern • Physical Exam • Evidence of injury • Detailed neuro exam

19. Epilepsy: management • MS/ABC’s • Monitor VS and check blood glucose • Treat any injuries • Transport to appropriate hospital • IV and ALS monitor: • Multiple seizures • Single seizure without return to baseline state • Atypical seizure (type or pattern) Reference REMO Protocols M-2 Active Seizures

20. Case 3 • 19 y/o female college student who “fell out” at a party. Witnesses describe generalized seizure activity. Confused/combative upon EMS arrival. • What more do you need to know? • What do you look for on exam? • What is your assessment and plan?

21. Differential Considerations • Syncope • Hyperventilation syndrome • Prolonged breathholdling • toxic and metabolic disorders • ETOH abuse/withdrawal • hypoglycemia • other CNS event (TIA, migraine, narcolepsy) • movement disorders (hemiballismus, tics) • Psychiatric disorders (fugue state, panic attacks) • Functional Disorders (pseudoseizure)

22. Characteristics of Seizure • abrupt onset • brief duration (90-120 sec) • Altered mental status (except simple partial) • purposeless activity • unprovoked (except febrile) • postictal state (except simple partial and absence)

23. First Time Seizure: Statistics • Rates of recurrence 23-71% • Predictors of recurrence • Etiology of seizure • EEG findings

24. Historical Information • History vital in determining the appropriate ED approach • description of event • preceding aura • loss of bowel/bladder • duration of event • post ictal period • clinical context (precipitating factors?) • febrile illness • head trauma • sleep deprivation • other stressor • baseline seizure pattern

25. Initial Assessment • No longer seizing: recovery position, IV, glucose, medication history • preventative medications? • Is seizing still: • Airway assessment (npa, suction, ETT prn) • protect patient from self injury • pulseox, monitor, IV access, blood glucose • (hypoglycemia is the most common metabolic cause of sz, but can also be a result of prolonged sz…needs to be treated aggressively either way) • abortive therapies

26. Detailed Physical Exam • Done after cessation of seizure activity • assess for injuries • posterior shoulder dislocation common • Temperature assessment • Bedside glucose determination • Cardiac Monitor • Assess for presence of systemic disease, toxic exposure, infection, focal neurologic event • serial neurologic exams • Todd’s paralysis: focal deficit following a seizure lasting less than 48 hours

27. Typical Physical Exam Findings • HTN, tachycardia, tachypnea during seizure activity • incontinence, vomiting, tongue biting • low grade temp common after generalized seizure

28. First Time Seizure: Management • MS/ABC’s • Monitor VS and check blood glucose • IV access (draw labs) • Cardiac monitor • Treat any injuries • Transport to appropriate hospital • No benzodiazepines unless seizure recurs or continues Reference REMO Protocols M-2 Active Seizures

29. Case 4 • 6 y/o WF presents s/p “seizure.” During transport EMS witnesses a generalized tonic-clonic event. • What more do you need to know? • What do you look for on exam? • What is your assessment and plan?

30. Status Epilepticus: Considerations • continuous clinical or electrical seizure activity or repetitive seizures with incomplete neurological recovery for >30 min • Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min) • impending SE if >3 tonic-clonic seizures within 24hrs • Generalized or Partial

31. Status Epilepticus: Considerations Generalized convulsive activity results in: • hypoxia • hyperpyrexia • BP instability and cerebral dysautoregulation • respiratory and metabolic acidosis • hyperazotemia/hypokalemia/hyponatremia • hyperglycemia followed by hypoglycemia • marked elevations of prolactin, glucagon, growth hormone and corticotropin • rhabdomyolysis may produce myoglobinuria and renal failure

32. Status Epilepticus: Statistics • 195,000 episodes in US annually • 42,000 deaths annually in US • 50% due to acute CNS insults (anoxia, TBI, CVA, neoplasm, infection) • peds: fever/infection • elderly: cerebrovascular disease • 20% in epileptic patients during med adjustment or due to noncompliance • 30% undetermined etiology

33. Status Epilepticus: Assessment • HPI/AMPLE • Detailed exam and history taking done once seizure has been stopped and patient has been stabilized

34. Status Epilepticus: Management • Rapid Seizure control • Patients do better when seizure treated by EMS • Step 1: • ABC’s • NPA, OPA, ETT • If RSI needed use only short acting paralytics • blood glucose • Cardiac Monitor • IV access • HPI/PE • Further specific treatment based upon circumstance

35. Status Epilepticus: Management • Step 2: 1st line drugs • Step 3: 2nd line drugs • Step 4: 3rd line drugs • The longer the seizure continues; • The more difficult it is to stop • The more likely permanent CNS injury will occur

36. Medication Options • First line • diazepam (Valium) IV/ET/IO/PR • lorazepam (Ativan)IV/IN • midazolam (Versed)IV/IM/IN • Second line • phenytoin/fosphenytoin • phenobarbital • Lastly induction of anesthesia w. cont. EEG • Infusions of midazolam, diprivan, valproic acid, pentobarbital • Inhaled isoflurane

37. Rectal Route of Administration • Surface area=200-400 cm2 (1/10,000 absorptive area of small intestine) • Highly vascularized • Passive diffusion

38. Rates of Diazepam Absorption by Various Routes Moolenaar F. Int J Pharma. 1980.

39. First Line Anticonvulsants

40. Second Line Anticonvulsants

41. Third Line Anticonvulsants

42. Conclusions • Seizures are common presenting problems to EMS. • Status epilepticus must be treated rapidly to avoid significant morbidity. • Familiarity with protocols and medication options is crucial.

43. Questions?

44. References • American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg Med. May 1997;29:706-724. • ACEP, AAN, AANS, ASN: Practice parameter: Neuroimaging in the emergency patient presenting with seizure (summary statement). Ann Emerg Med. 1996;28:114-118. • Smith, BJ. Treatment of Status epilepticus. Neurologic Clinics. May 2001;19:2 • Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emergency Medicine Clinics of North America. Feb 1999;17:1

45. References cont’d • Goetz. Epileptic Seizures. Textbook of Clinical Neurology, 1st ed. WB Saunders 1999. pp1062-1079 • Pollack CV. Seizures. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th Ed. Mosby 2002. Pp145-149 • Hanhan UA, Fiallos MR, Orlowski JP. Status Epilepticus. Pediatric Clinics of North America. Jun 2001;48:3 • Lahat E, Goldman M, Barr J, et al. Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. BMJ. July 200;321:83-86 • Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children. Neurology. Sept 2000;55:5