STEP BY STEP MANAGEMENT OF Seizures / STATUS EPILEPTICUS

1. STEP BY STEPMANAGEMENT OFSeizures / STATUS EPILEPTICUS Dr. D. Alvarez 2007

2. INITIAL PROCES • Call from the ED requesting bed for a patient with Seizures / Status Epilepticus. • PICU Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED. • Information needed: • Base line patient’s: Previously healthy Or if any chronic condition. - If previous diagnosed with Seizures > since ? age • Taking medications? Name, doses, Since when • time last dose ?, did tolerated or vomited? • Follow up by Neurology? Last visit • Previous studies (head CT, MRI) • Seizure control • Last Hospitalization?; intubation?; ED visit?

3. INITIAL PROCES (continue) B. Is this is first Episode? Information of Current event/exacerbation: • Triggering factors, fever? Trauma?, medications? Or No obvious triggering /“Unprovoked” • Describe seizures, • Focal?, generalized • Onset: when awake ?, sleeping?, watching TV? • Duration • Interventions? • Treatments / management at home. • EMS, findings - treatments if applicable

4. ED Events… (continue) 4.- Review ED-Events • Condition on arrival > mental status Post ictal? • Airway maintainable? / intubated for airway protection (Fill up Mechanical Ventilation Order guidelines if applicable) • Studies / labs done (Start laboratory flow sheets record) • Radiological studies: Head CT, CxR • Lab reports • Treatments given: note, dose and time. 5.- Communicate with PICU Attending and inform on patient’s condition using the “30 sec assessment guideline” 6.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

5. ASSESSMENT

6. Physiological Problems that need to be Address / Assess. • Is Airway maintainable? / Secured (intubated) • Is Ventilation and oxygenation adequate • O2 Sats RA or % O2 needed • RR, deepness of respiratory effort, air entry. • ABG if patient is intubataed • Mental Status changes, any effect of medications given. • Focal neuro findings? • Pupilary reaction

7. 3. Cardiovascular Assess • HR, Rhythm / Tachycardia • BP: Hypertension, hypotension, perfusion. 4. Hydration Status / Fluid-Electrolyte and ABB. • FS: hyperglycemia / hypoglycemia • Hyponatremia / hypernatremia • Metabolic acidosis

8. Assessment > If associated infection Process. • By History • Fever • Respiratory symptoms • GI symptoms: vomiting / diarrhea • Travelinig • Contacts. • By Physical exam • By Studies: • CBC with diff (manual count) if clinically indicated • CxR, (if respiratory symptoms) looking for signs of aspiration. • Blood, U/A, CSF culture if indicated.

9. MANAGEMENT

10. Initial Management (0-10min) • ABC • OXYGEN should be given to all pat.actively seizing and/or alter mental status. • Open airway • Position patient • Assess if adequate ventilation • Observe for depth of respiration • Listen for air entry • Start IV • Check FS • Send for basic studies (CBC, Lytes)

11. Initial Management (10-20min) • If hypoglycemia give • D25 > 2 ml/kg • Anticonvulsant Medication (see precalculated dose/drip protocole) • Lorazepan 0.1 mg/kg (2 mg/min) OR • Diazepan 0.2 mg/kg (5mg/min) OR • Diastat PR • 1-5 y ……….. 0.5 mg/kg • 6-10 y ……….. 0.3 mg/kg • > 12 y ……….. 0.2 mg/kg Repeat ONCE if seizure does not stop within 5-10 min

12. Management Cont.(20-40min) Keep Patient on continues C-R monitoring with • frequent VS including BP and • monitoring A&B, keep airway open and continue given oxygen. 4. Fosphenytoin: • 20 mg/kg (slow infusion 150 mg/min, pat. On continuous monitoring) • If seizure persist, give additional 10 mg/kg AND / OR 5. Phenobarbital • 20 mg/kg (50 mg/min) POST BOLUS BLOOD LEVEL SHOULD BE DONE IN 1-2 HRS POST INFUSION.

13. Management > 60 min) Refractory Status • Intubate • Premedicate with: • Midazolan: • 0.1 –0.3 mg/kg Load F/U by • 0.05-0.4 mg/kg/hr Maintenance And / OR • Pentobarbital • 5-20 mg/kg load • 0.5-5 mg/kg/hr Maintenance

14. Intubation Process • Call anesthesia (Emergency Beeper posted) if PICU attending not in house) • Calculate / Order / Prepare Medications • Rapid Sequence (RSI) INTUBATION MEDICATIONS • Midazolam: 0.05 to 0.1 mg/kg • Pentobarbital • 5-20 mg/kg load • 0.5-5 mg/kg/hr Maintenance Call Respiratory therapy

15. Principles of Mechanical Ventilation Support • Order initial Mechanical Ventilatory setting according to guidelines after discussion with PICU attending • Continues drip (if indicated) with: • Midazolan: 0.05-0.4 mg/kg//min OR • Pentobarbital: 0.5 – 5mg/kg/hr.

16. Fluid Therapy NPO until patient is awake and responsive Calculate patient’s maintenance fluids (requirements); Wt. base OR per SA(m2) A. Basic Requiremente • Wt base: • 100 ml/kg for the first 10 kg • 50 ml/kg for the next 10 kg • 20 ml/kg for the rest…. kg. • Per SA (m2) 1500 mL/M2 B. Add Insensitive extra loses given by: • Tachypnea • Fever Check electrolytes, follow up Glucose

17. Dilantin (To be use only in case that phosphenitoin not available) • Remember, this is consider a High Risk Medication, because serious side effect if not given correctly. • This are the recommendations • Dilute only in Normal Saline just before infusion. Not soluble in D5W and will precipitate. • 1 gm in 100 mL OR 500 mg in 50 mL of NS • Infusion rate at no faster than 50 mg/min by pump. • 5 mL/hr of either solution 1 gm in 100 ml or the 500 mg in 50 mL of NS solution • Monitor EKG and BP during infusion • Do not give Dilantin IM • The dose is 15 to 20 mg/kg • Adverse reactions: Hypotension, Bradicardia, phlegitis, purple glove syndrome.