Epilepsy Emergency:- Treatment of seizures in the ER

"Epilepsy Emergency:- Discussion of the management of epileptic emergencies in the ER"

Document seizures accurately with this chart

Submitted to AskTheNeurologist.Com in 2007Author Anon.

The first seizureIs it really first event?

If established that it is, in fact first, unprovoked event decision to treat depends on - risk factors for recurrence - risks of drug treatment - patient preference

Epilepsy in the ER

Seizure recurrenceOver 50% of patients who will have recurrence following first seizure will do so within 6 monthsRecurrence rate varies from 36 – 77%If careful history taken to ensure seizure is definitely “ first ever” then recurrence rate drops to 35%Recurrence rate following second seizure is 80-90%Risk factors for seizure recurrenceHistory of prior neurological injury or lesion

History of epilepsy in a sibling

Transient neurological deficit ( Todd’s )

EEG with generalised epileptiform dischargesTreatment of status epilepticusAcute Epilepsy emergency management - Prevents injuryEpilepsy Emergency in the ER
Rational drug administration - Limits morbidity due to systemic changes or seizure-induced neuronal damageDefinitionsILE: “ seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur”Most literature specifies time period of 20-30 minutes as estimate of time necessary to cause injury to CNSOperational definition“ Continuous seizures lasting at least 5 minutes or 2 or more discrete seizures between which there is incomplete recovery of consciousness”Predictors of outcomeAgeCause - Metabolic - Infection - CVA - Trauma

OutcomesOverall mortality is 20%Patients whose first ever seizure is status epilepticus have substantial risk of future episodes and the developmennt of chronic epilepsyPredominant factor affecting outcome is causeMyoclonic status epilepticus after hypoxia carries especially grave prognosisDuration of status epilepticus is correlated with neurological morbidity and lack of responsiveness to drug treatmentAssessment and supportive measuresABC - protect airway100 % O2BP control

GlucoseHypoglycemia should be excluded

Usually treat empirically with 50ml of 50% glucose

Should always precede glucose administration with 100mg thiamine IVBlood pressureHypertension usually occurs early in course

Subsequently BP labile and often drops

Fluids and vasopressors may be required

Aim for high/normal rangeBody temperatureMay often be result of seizures themselves rather than co-existing infection

Should be treated with passive coolingSystemic treatmentAvoid over-hydration ( cerebral oedema )Blood tests ( including Ca, Mg)Monitor oxygenationMonitor rectal temperature

1st line drug treatmentsBenzodiazepines - Diazepam vs Lorazepam

Phenytoin vs Fosphenytoin

PhenobarbitalBenzodiazepinesLorazepam“ Despite their equivalence as initial therapies, lorazepam has a longer duration of antiseizure effect ( 12-24 hours ) than diazepam ( 15-30 minutes)…..lorazepam preferable to diazepam for the treatment of status epilepticus”FosphenytoinWater-soluble prodrug form of phenytoinDoes not contain propylene glycol ( which is main limiting factor for rate of treatment as contributes to cardiovascular side effects)Less irritantCan be given at a maximum rate of 150 phenytoin equivalents / minute Phenytoin itself may only be administered at a maximum rate of 50mg/minMaximal brain concentrations of phenytoinAttainable in 20-25 minutes when phenytoin infused at maximal rate

Attainable within 10 minutes when Fosphenytoin infused at maximal ratesPhenobarbital“ Highly effective”

Recommend 20mg/kg at rate of 50 – 75 mg/min

Risk of apnea….especially if patient has received BZD’sIV Valproic acidEffective in some forms of status epilepticus

At time of publication insufficient experience availableRefractory status epilepticusFailure to control seizures with BZD’s, phenytoin and phenobarbitalRequires administration of iv anaesthetic agent - Barbiturates - Midazolam - PropofolEEG performed at 12hrs and thereafter every 24 hoursseizures in the ER

Recommendations regarding BarbituratesSevere hypotension requiring pressor therapy limits safety of barbiturates

Preferable to reserve anaesthesia with barbiturates for patients in whom midazolam or propofol fails

Epilepsy Emergency / Epilepsy in the ER lecture end