SEIZURE MANAGEMENT IN THE ADULT Andy Jagoda_ MD

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SEIZURE MANAGEMENT IN THE ADULT Andy Jagoda_ MD Powered By Docstoc
					Seizure Management in the
ED: Putting It All Together

    Andy Jagoda, MD, FACEP
Professor of Emergency Medicine
 Mount Sinai School of Medicine
      New York, New York
Approach to pt who has sz
and returned to baseline Patient who has seized and returned to baseline


                                                      First time


                  yes                                                                           no
                        B
                                                                                       same as past events
 Assess for drug use head trauma,
 medical illness medications, pregnancy,
 hypoglycemia, focal neuro exam                                                                          yes
                                                                                       no
                       B                                                                                       C
         Obtain electrolytes, glucose
         pregnancy test in woman
                                                                                                check AED level
                       C                                                                        assess for factors that
   Consider need for CBC, LFTs,                                                                 lower seizure threshold
   Ca, Mg, PO4, drug of abuse                                                                                  C
   screen alcohol level
                                           Focal neurologic exam             HIV + OR
                                                                          Immunocompromised
                                                                                            B      If on phenytoin
                                           yes             no B                                    and subtherapuetic
                                                                                  CT / LP
                                                                                                   load with IV, POo,
                                                     CT in ED OR Arrange                           IM
                                        CT in ED     CT as an outpatient
                                                                 C
                                            Discharge for outpt workup / Do not start AED
                         Patient seizing
                                                               Clinical pathway for status epilepticus
    Assess and secure the ABCs; Protect the patient from                          Assess need for:
    harm; Check glucose and give dextrose if <80                                  Antibiotics
    Perform a physical assessment; Monitor vital signs,                           Charcoal
    ECG, pulse oximetry                                                           Toxin specific therapy (eg B6, HCO3)

                                                                            Send blood for:
         Seizure stops                     Seizures continue                  pregnancy test, CBC, electrolytes
         See pathway I                             C                          AED levels
                                    Lorazepam, 2 mg / min to a max of 10 mg Consider sending blood for:
                                    (.1 mg/kg in children)                    Mg, Ca, PO4, LFTs, ETOH,
                                                                              toxicology screen / levels

                                      sz# stops     sz continues
                                                         C
                                           Phenytoin 18 mg / kg at 25-50 mg / min##
                                           or
                                           Fosphenytoin 18 PE */ kg at 150 mg / min

                                             sz stops   sz continues
                                                               C
                                                  Repeat phenytoin or fosphenytoin at 1/2 the initial dose
                                                  or phenobarbital 20 mg / kg at 100 mg / min


                                                   sz stops      sz continues
Observe and prepare for a second event
                                                                   C
    Observe
    Prepare for another seizure
                                           Pentobarbital,** 3-5 mg / kg at 25 mg / min then drip at .5 - 3 mg / min
                                           or
                                           Midazolam 200 ug / kg bolus then 1-10 ug / kg / min
                 C                         or
                                           Propofol 1-2 mg / kg bolus then 2-10 mg/kg/hr
 Consider bedside EEG



  Reassess patient
  Intubate at any time airway or breathing is compromised
  Consider CT / LP




# sz = seizure

## slower rates for patients with cardiovascular disease. infusion shouldbe through a large bore IV

* PE = phenytoin equivalent

** watch for hypotension and treat initially with fluids; dopamine if needed

AED = antiepileptic drug
 1:00 AM: EMS Called for a
      Patient Seizing
• Witnesses report that
  patient druank 3-6 beers
• Patient ingested a “dot” of
  LSD 2 hours prior to EMS
• Patient asked for “help”
  then fell to floor seizing
• No history of trauma
• No other history available
                         Andy Jagoda, MD
1:10 AM: EMS Arrived and Called for
   Activation of Seizure Protocol
  • Patient in status epilepticus
  • BP 130/90, RR 20, P 110
  • Dextrostix 120
  • Pulse oximetry 98% saturation
  • IV access established
  • Diazepam 5 mg IV Q 5 min to a
    max of 20 mg
  • Estimated ETA: 20 minutes
                           Andy Jagoda, MD
1:30 AM: Patient Arrived in the
         ED Seizing
  • Diazepam 20 mg given in
    the field
  • BP 130/90, P 110, RR 20,
    Rectal T 37
  • BS and Pulse Ox
    unchanged

                         Andy Jagoda, MD
          Physical Exam
• Tonic clonic activity
• WDWN: No evidence of
  immunocompromise
• No signs of trauma
• No signs of intravneous drug use
• Unresponsive to verbal or painful
  stimuli
                            Andy Jagoda, MD
     Physical Exam

• PERL: Dilated to 8 mm

• Gaze away from the
 examiner

• Gag intact

• No incontinence
                       Andy Jagoda, MD
PHYSICAL EXAM




THE VIDEO



                Andy Jagoda, MD
  The Results of a
Diagnostic Test was
     Obtained
       Laboratory Tests

• Electrolytes: NA 143, K 4.1, CL
  108, HCO3 24
• Alcohol: 120 mg/dl
• CPK: 240 ng/mL
• Tox Screen for DOA: Normal
Arterial Blood Gas: pH 7.44, pO2
  110, pCO2 36, 100% saturation
                         Andy Jagoda, MD
A Dx of Psychogenic Status
   Epilepticus was Made
• Patient was given verbal
  suggestions that the seizures
  would stop if he concentrated
• While still “seizing” the patient
  began to cry for help
• Over 10 minutes the “seizures”
  slowly subsided
                           Andy Jagoda, MD
        Past Medical History
• Similar but brief event since age 10
  • Focal
  • Controlled with concentration
• Events always occurred in association
  with stressful situations
• Emotional and physical abuse as a
  child
  • Father beat him
  • Chained to the bed
• Presently under stress from losing job
                                    Andy Jagoda, MD
        The LSD “Trip”
• Recalled initial euphoric feeling
• Recalled floating sensation
• Followed by strong visual
  distortions
• Remembers becoming panicked
  that he could not control himself
• Remembers the seizure and all
  care given              Andy Jagoda, MD
Physical Findings Suggestive
  of Psychogenic Seizures

  • Out of phase movements
  • Pelvic thrusting
  • Head turning side to side
  • Dilated pupils, reactive to
    light


                         Andy Jagoda, MD
Howell et al. Pseudostatus epilepticus.
     Q J Med. 1989;71:507-519
      • 40% of patients transferred
        in “status epilepticus”
        were in psychogenic
        status
      • Estimated 5% TO 20% of
        patients referred to
        epilepsy centers have
        psychogenic seizures
                            Andy Jagoda, MD
Criteria for a Conversion Disorder
  • Alteration in physical
    functioning
  • Psychological factors involved
  • Symptoms are not unders
    voluntary control
  • Symptoms are not explained
    by a physical disorder
                             Andy Jagoda, MD
          Conclusions
• Management of a patient with a first
  time seizure is based on a careful
  neurologic exam, and the results of a
  chemistry panel, head CT, and EEG
• Oral phenytoin loading provides
  “therapeutic” serum levels four hours
  post-load in most cases
• Lorazepam is the best first line
  treatment for seizures
                           Andy Jagoda, MD
           Conclusions
• In refractory status epilepticus,
  pentobarbital, midazolam, or
  propofol are third line agents
• Psychogenic seizures are
  characterized by out of phase
  motor activity, forward pelvic
  thrusting, voluntary eye
  movements, normal mental
  status
                            Andy Jagoda, MD

				
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posted:1/5/2013
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