SEIZURE Flashcards
MANAGEMENT: STATUS EPILEPTICUS
- Call for help
- Assess ABCDEFG (ABC and Don’t Ever Forget About Glucose)
A:
Lateral decubitus/recovery position
Ongoing suction, Clear airway of: blood, food, mucus etc.
Jaw thrust if tongue is occluding airway
Bag Mask Ventilation
Consider Oropharyngeal airway or nasal trumpet
Move away sharp objects, pillow for head
Maintain cervical spine immobility if suspected head trauma
DO NOT USE A BITE BLOCK
RSI if Necessary, use Midazolam and Propofol
Intubate prior to anesthetics
B: O2 if necessary
3.
C: MOVIES
Ensure 2x IV access
Use IM if IV not available
- D: Accucheck STAT -> 1 amp D50W (+/- thiamine if hx of alcoholism) OR Glucagon 1 mg IM if IV not available
Most seizures last 1-2 minutes and self resolve
POC ABG / VBG for Sodium
Administer Benzodiazepines
- Rapid Neurologic Exam
BENZODIAZEPINE
Benzodiazepines: first line
Lorazepam (Ativan): 2-4 mg (0.01-0.03 mg / kg IV or IM, max 0.1 mg / kg or 8 mg)
(Onset within 2 min, lasts 4-6 hrs)
OR
Midazolam (Versed): 5-10 mg (0.05 mg / kg) IV
(10 mg IM if IV not available; IM, IN, IV or PR available)
OR
Diazepam (Valium): 5-10 mg IV (0.1 mg / kg IV)
(Onset within 30 secs, last < 20 min)
REFRACTORY
1. Give 2nd & 3rd dose of benzodiazepine
- Load with Phenytoin
20 mg/kg IV loading dose at a rate of 50 mg / min, max 1500 mg
Watch BP and telemetry for arrythmias
Do NOT use for suspected toxic overdose (lidocaine, cocaine, theophylline)
OR
KEPPRA: 40-60 mg / kg IV loading dose at a rate of 5-15 min), max 2000-4000 mg IV load
Fosphenytoin: 20 mg/kg IV loading dose at infusion of 150 mg/min
REFRACTORY > 10 MIN
1. Additional dose of phenytoin: 10 mg / kg IV (750 mg IV)
- Intubation
- Consult ICU
- 3rd Line Med:
Phenobarbitol 20 mg/kg IV at 50 mg/min
+/-
IV Propofol 1-2 mg / kg bolus, repeat q3-5 min THEN 2-10 mg /kg / hr
OR
Midazolam 0.2 mg / kg IV bolus THEN up to 0.6 mg / kg / hr IV infusion
INVESTIGATIONS
STAT Glucose
Na, Ca
BUN, Cr
LFTs
CK
BHCG
ECG - exclude Arrythmia
Anticonvulsant levels
ETOH / Tox screen
+/- blood cultures / TSH
CT head if first episode or concerning history / physical
+/- Lumbar Puncture
CONSULT:
Medicine / Neurology
MONITOR
cardiac monitor / neurovitals
hyperthermia rhabdomyolysis
lactic acidosis
MANAGEMENT: ECLAMPSIA
First Line:
Magnesium Sulfate
4-6 g IV over 20 min, followed by an infusion of 1-2 g / hr
Second Line: Benzodiazepines
Hydralazine 5-10 mg IV, repeated every 20 minutes (max 20 mg)
Labetolol 10-20 mg IV push over 2 minutes, double the dose repeated every 10 minutes (max 80 mg/dose) (max total dose 300 mg)
Delivery of Fetus
MANAGEMENT: HYPOGLYCEMIA
D50 IV push (50 mL, 25 g)
MANAGEMENT: HYPONATREMIA
3% NaCl, 100 mL infusion over 10 min
MANAGEMENT: ISONIAZIDE
Pyridoxine (Vit B6) 1 g IV for each 1 g Isoniazid ingested
OR
5 g for an unknown ingestion
DOCUMENTATION
STATUS EPILEPTICUS
Seizures lasting more than 5 min or more than 2 seizures without recovery of consciousness
CLINICAL FEATURES
Can have focal onset (E.g. typical aura and complex partial
seizure prior to event)
> 10 seconds of stiffening or jerking
Tongue bite/urinary incontinence
Foaming at the mouth
Post ictal period
Can injure self with fall or find
body bruises, soreness on waking
HPI
Witnessed
Duration of episode
Tonic / Clonic Activity
Loss of Consciousness
Tongue bite (laternal tongue biting 96%-100% specific)
Urinary incontinence (38% sensitive and 57% specific)
Foaming at the mouth
Post ictal period
Any other injuries
Triggers:
Trauma
Substance abuse or withdrawl
Missed medication, medication change
Fever, Infectious symptoms
Metabolic causes (hypoglycemia, hypoxia, vomiting, diarrhea)
Stress, sleep deprivation
Recent birth / delivery
PMHx:
Epilepsy, intracranial mass / bleed / ischemia, head trauma, diabetes, renal failure, Cancer / Immunocompromized, Febrile seizures
Meds: AED’s, common meds that induce seizures
SoHx: EtOH, drug abuse: sedatives, sympathomimetics, synthetic cannabinoids
Fingerstick Glucose
Monitor vital signs: HTN, Tachycardia, Hyperthermia
Secondary Survey:
GCS
Focused Neurological Exam, Automatisms
HEENT: Tongue injury, Head Trauma
Incontinence
Inspect for injuries
DISPOSITION
Patients with a first unprovoked seizure with a return to baseline and a negative laboratory and radiographic workup do not need hospitalization
Patients should be cautioned against driving, bathing, and other activities during which unexpected loss of consciousness would be dangerous for at least 6 months
MTO Report
Neurology follow-up should be arranged from the ED, if possible, for outpatient magnetic resonance imaging (MRI) and EEG
Notify Ministry of Transportation
DDX
Syncope
Complex Migraine
TIA
Functional Seizures
DDX
Head Trauma
CNS
Ischemic or hemorrhagic stroke
Neoplasm
Epilepsy
AVM
Hydrocephalus
Degenerative CNS disease
Eclampsia
Neurosurgery
METABOLIC
Hypo / Hyperglycemia
Hyponatremia
Hypocalcemia
Uremia
Hepatic Encephalopathy
Thyrotoxicosis
TOXIC
Antidepressant (SSRI, SNRI, TCAs, Bupropion)
ASA
Tramadol
Isoniazid
Diphenhydramine
Theophylline
Cocaine / Amphetamine
LSD
Carbon Monoxide
WITHDRAWL
Alcohol
Antiepileptic drugs
Benzodiazepines
DDX ETIOLOGY
Hypoglycemia
Hyponatremia
Hypocalcemia
Isoniazid
Eclampsia
Overdose
