Optimizing Seizure and SE Patient Management in the Emergency Department

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Optimizing Seizure and SE Patient Management in
the Emergency Department
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SIMEU / ACEP Emergency MedicineCongress
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Turino, Italy November 9-11, 2006
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Edward P. Sloan, MD, MPH ProfessorDepartment
of Emergency MedicineUniversity of Illinois
College of MedicineChicago, IL
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Attending PhysicianEmergency
MedicineUniversity of Illinois HospitalOur
Lady of the Resurrection HospitalChicago, IL
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(No Transcript)
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Disclosures

• NovoNordisk, King Pharmaceuticals, UCB Pharma
  Advisory Boards
• Eisai Speakers Bureau
• ACEP Clinical Policies Committee
• ACEP Scientific Review Committee
• Executive Board, FERNE
• FERNE support by Abbott, Eisai, Pfizer, UCB

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Board Chairman and PresidentFERNEChicago, IL
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OverviewMission Statement

• Patients with neurological emergencies deserve
  quality emergency care.
• Quality scientific research.
• Case-oriented, evidence-based medical education
  on optimal acute neurological care.
• Use of technology to break down space and time
  barriers.
• Advocacy.

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www.ferne.org
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A Special Welcome To
Gabriella Paglia, MD Department of Emergency
NeurologyAz. Ospedaliera S.Giovanni Battista
di TorinoCap 10126 TORINOC.so Bramante,
88/90Italy
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Todays Agenda

• Present a clinical case
• Ask a few questions
• Consider the possibilities
• Discuss ED management
• Examine the patient outcome

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A Clinical Case
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Patient EMS Data

• 50?? yo male John Doe
• Generalized tonic-clonic seizure
• Chicago Fire Department
• Diazepam 5 mg IM, 15 mg IV
• Seizure continuous for 15 minutes
• EMS to ED
• No change in status

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Patient Clinical History

• Unknown meds
• Unknown medical history
• Hx Needs surgery next month ??
• EtOH ??
• Does not appear to be homeless
• Accucheck 119

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ED Presentation

• Facial and shoulder twitching R
• Pt with gurgling BS
• Nasopharyngeal airway
• No evidence of trauma or toxicity
• IV access in neck
• Seizure persists x minutes

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Seizure Patient Questions

• Is this a seizure?
• Is this status epilepticus?
• What is the pathophysiology?
• What is the best management?
• What is the likely patient outcome?

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Seizure/SE Clinical Data
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SeizuresGeneralized Seizures

• Primary generalized starts as tonic-clonic sz
• Secondarily generalized tonic-clonic sz
  develops from a non-convulsive partial sz, ie
  aura (common)

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Status Epilepticus

• Sz gt 5- 10 minutes
• Two sz without a lucid interval (Assumes ongoing
  sz during coma)

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Status EpilepticusSE Classification

• GCSE (Generalized convulsive SE) with
  tonic-clonic motor activity
• Non-GCSE

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Status EpilepticusTwo Non-GCSE Types

• Non-convulsive SE
• Absence SE
• Complex-partial SE
• Subtle SE
• Late generalized convulsive SE
• Coma, persistent ictal discharge
• Very grave prognosis

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Status EpilepticusSystemic SE Effects

• Hypertension (early)
• Hypotension (later)
• 49 will have temp gt 100.5 F
• Lactic acidosis
• Hypercarbia

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Status EpilepticusOngoing SE Effects

• Over 40-60 min, loss of metabolic compensation
• With ongoing SE, systemic BP CBF drop

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Status EpilepticusSE Mortality

• SE mortality gt 30 when sz longer than 60 minutes
• Underlying sz etiology contributes to mortality

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General ED Management

• ABCs
• Glucose, narcan, thiamine
• Rapid sequential use of AEDs
• Directed evaluation

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ED ManagementSE Rx Timeline

• 0-30 min ABCs, benzos
• 30-60 min Phenytoins
• 60-90 min Levetiracetam, phenobarbital,
  valproate
• 90-120 min Midazolam, propofol
• CT, EEG, ICU/OR

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ED Anti-epileptic Drug (AED) Use
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Seizure Pharmacotherapy

• Benzodiazepines
• Phenytoins
• Barbiturates
• Other agents
• levetiracetam
• propofol
• valproate

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PharmacotherapyGeneral AED Concepts

• Most drugs are at least 80 effective in Rx
  seizures, SE
• Have AEDs available in ED
• Use full mg/kg doses
• Maximize infusion rates in SE

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PharmacotherapyBenzodiazepines

• GABA inhibition
• Diazepam short acting, limited AMS and
  protection (intubation more common)
• Lorazepam prolonged AMS and protection
• Pediatric sz IV lorazepam limits respiratory
  compromise

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PharmacotherapyRectal Diazepam

• Diazepam rectal gel pre-packaged for rapid use
• Dose 0.5 mg/kg, less respiratory depression seen
  than with IV use

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PharmacotherapyPhenytoin

• Stabilize memb Na channels, regulate Ca
  channels
• For generalized sz, and SE
• Constant infusion over IVP
• Use pump to prevent comp
• Therapeutic at 10-20 µg/mL

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PharmacotherapyOral Phenytoin

• 18mg/kg oral load
• 64 reach 10mg/mL levels by 8 hrs (therapeutic)
• Delayed absorption due to large loading, or drug
  prep

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PharmacotherapyFosphenytoin

• Pro-drug, dose same as pht
• Infuse at 150 mg/min in SE
• Can be given IM up to 20cc
• Level 10-20 µg/mL
• Delayed level 2h IV, 4 h IM

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PharmacotherapyIV Levetiracetam

• Second generation AED
• Oral and IV bioequivalent
• Adjunct therapy
• No therapeutic level defined
• 1500 to 3000 mg infusion
• Few adverse effects

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PharmacotherapyIV Phenobarbital

• GABA-inhib, effective SE Rx
• Infuse up to 50 mg/min
• 20-30 mg/kg, 10 mg/kg doses
• Therapeutic gt 40 µg/mL
• Respiratory depression
• Hypotension

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PharmacotherapyIV Valproate

• Likely GABA mechanism
• Useful in peds, possibly SE
• Rate up to 300 mg/min
• 25-30 mg/kg, 3-6 mg/kg/min
• Therapeutic gt 100 µg/mL

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PharmacotherapyIV Midazolam Infusion

• GABA mechanism
• Equal to diazepam infusion
• Greater breakthru sz rates
• Less hypotension
• vs. propofol, pentobarb

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PharmacotherapyIV Propofol Infusion

• Likely GABA mechanism
• Provides burst suppression
• 2 mg/kg loading dose
• Hypotension, acidosis, hypoventilation
• Rapid onset, easily reversed

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PharmacotherapyIV Pentobarbital

• Likely GABA mechanism
• Provides burst suppression
• 5 mg/kg loading dose
• 25 mg/kg infusion rate
• ICU monitoring required

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PharmacotherapyED Treatment Protocol

• Have AEDs easily available
• Rapid sequential AED use
• Maximize infusion rate
• Maximize mg/kg dosing
• Benzos, phenytoins, other bolus AEDs, continuous
  AEDs

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PharmacotherapyNo IV Access

• PR diazepam
• IM midazolam
• IM fosphenytoin
• Buccal, intranasal midazolam
• No IM phenytoin/phenobarbital

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ED Patient Outcome
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ED Patient Management

• Lorazepam 2 mg IVP x 5 over 10 minutes
• Persistent facial and R shoulder activity
• AMS generalized seizure continues
• Fosphenytoin 1 gram PE over 10 min
• Fosphenytoin 1 gram PE over 10 min
• Seizure ended, pt remained obtunded
• Intubation immediately followed
• Lidocaine, sux, rocuronium

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ED Diagnostic Evaluation

• Non-contrast CT Prior strokes, atrophy
• Metabolic tests normal
• Toxicology screening negative
• Phenytoin level cancelled
• Diagnoses
• AMS
• Status Epilepticus
• Respiratory Failure

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Family Arrives, Pt History

• Pt with history refractory seizures
• Hx carotid artery occlusion R
• Due for carotid endarterectomy
• Phenobarbital dilantin, compliant
• Prior history of SE treated at UIC
• No medic alert bracelet
• No recent illness, trauma, EtOH

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Patient Outcome

• EEG in ED, within 150 minutes
• Neuro consultation, no subtle SE
• Admit to Neuro ICU
• Repeated paralytic dosing
• Final disposition for carotid Rx

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Conclusions

• ED seizure patient Rx needs to address both the
  immediate seizure and the long-term epilepsy
  management
• In general, ED seizure patient Rx focuses on
  parenteral AED use
• Must understand principles that govern ED AED use
  and priorities of those that provide long-term
  epilepsy Rx

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Recommendations

• Be able to identify the seizure type and optimal
  patient therapies based on etiology,
  demographics, and risk/benefit
• Establish seizure and SE protocol
• Stop the acute seizure prevent SE
• Wisely prescribe so that follow-up epilepsy
  management can be optimized

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Questions?
www.FERNE.org edsloan_at_uic.edu 312 413 7490
ferne_simeu_2006_sloan_seizure_111006_final 11/15/
2009 715 PM (11/10 646 am)