The Management of Seizures and SE in the Emergency Department

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The Management of Seizures and SE in the
Emergency Department
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Edward Sloan, MD, MPH, FACEP

• Associate Professor
• Research Development Director
• Department of Emergency Medicine, University of
  Illinois at Chicago
• Chicago, IL
• (edsloan_at_uic.edu)

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Global Objectives

• Learn more about seizures
• Increase awareness of Rx options
• Enhance our ED management
• Improve patient care outcomes
• Maximize staff patient satisfaction
• Be prepared for the EM board exam

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Session Objectives

• Provide seizure and SE overview
• Summarize what Rx options exist
• Discuss specific sub-groups
• Outline ED Rx strategies

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Sz Epidemiology

• Epilepsy seen in 1/150 people
• For each epilepsy pt, 1 ED visit every 4 years
• 1-2 of all ED visits
• Significant costs

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Seizure Mechanism

• Sz abnormal neuronal discharge with recruitment
  of otherwise normal neurons
• Loss of GABA inhibition

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Pathophysiology

• Glutamate toxic mediator
• Necrosis occurs even if systemic problems are
  treated (HTN, fever, rhabdomyolysis, resp
  acidosis, hypoxia)

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Pathophysiology

• Early compensation for increased CNS metabolic
  needs
• Decompensation at 40-60 minutes, associated with
  tissue necrosis

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Seizure Classification

• Generalized both cerebral hemispheres
• Partial one cerebral hemisphere

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Generalized Seizures

• Convulsive tonic-clonic
• Non-convulsive absence

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Generalized Seizures

• Primary generalized starts as tonic-clonic
  seizure
• Secondarily generalized tonic-clonic seizure
  occurs as a consequence of a non-convulsive
  seizure

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Partial Seizures

• Simple partial no impaired consciousness
• Complex partial impaired consciousness

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Specific Seizure Types

• Absence Petit mal
• Partial Jacksonian, focal motor
• Complex partial temporal lobe, psychomotor

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Status Epilepticus

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

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SE Epidemiology

• Risk of SE greatest at extremes of age
  pediatric and geriatric populations
• SE occurs in setting of acute insult, chronic
  epilepsy, or new onset seizure
• 150,000 cases per year

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SE Classification

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

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Two 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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AMS in Seizures

• Mental status should improve by 20-40 minutes
• If pt comatose, then subtle SE is possible EEG
• Up to 20 of pts with coma still are in SE

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Ongoing SE Effects

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

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SE Mortality

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

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Subtle SE

• Mortality exceeds 50
• Often after hypoxic insult
• Coma
• Limited motor activity
• Stop the sz, EEG confirm

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General ED Management

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

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Lab Evaluation

• Key lab abnormality hypoglycemia, in up to 2
• Directed labs, including anti-epileptic drug
  levels

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Lumbar Puncture

• Fever and CSF pleocytosis can occur in SE without
  meningitis
• Use clinical criteria to determine LP need
• AMS, immunocompromise, meningismus

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Neuroimaging with CT

• CT useful with focal sz, change in sz type or
  frequency, co-morbidity
• Reqd in new-onset sz
• Non-contrast unless mass lesion suspected

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Neuroimaging with MRI

• Useful with refractory sz
• Complements plain CT
• Can be done as outpt

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EEG Monitoring

• EEG to rule out subtle SE
• Prolonged coma, RSI, induced coma with propofol,
  pentobarbital
• Obtain EEG in 120 minutes
• Two-lead EEG in ED

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AED loading

• Repeated seizures, high-risk population,
  significant SE risk
• No need to determine level in ED after loading
• Oral loading in low risk pts

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Hospital Admission

• Repeated sz, high-risk pt, significant SE risk
• Esp if no AED loading
• New-onset seizure admission is preferred
  (complete w/u, observe)

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New-Onset Sz Recurrent Sz

• 51 recurrence risk
• 75 of recurrent sz occur within 2 years of first
  sz
• Only a small of pts will seize within 24 h
• Partial sz, CNS abn inc risk

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ED Discharge

• Follow-up EEG needed, esp if no AED prescribed
• Driving documentation is critical. Know state
  law.

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Pharmacotherapy of Seizures

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

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General AED Concepts

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

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Benzodiazepines

• GABA drug
• Diazepam short acting, limited AMS and
  protection
• Lorazepam prolonged AMS and protection
• Pediatric sz IV lorazepam limits respiratory
  compromise

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Rectal 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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Phenytoin

• Phenytoin Na channel Rx
• Load at 18 mg/kg, 1.5 doses
• Infuse at 50 mg/min max
• Use pump to prevent comp
• Level 10-20 µg/mL

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Fosphenytoin

• Fos pro-drug, dose same
• 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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IV Phenobarbital

• GABA-like, effective sz Rx
• Limited availability
• Infuse up to 50 mg/min
• 20-30 mg/kg, 10 mg/kg doses
• Level gt 40 µg/mL

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IV Valproate

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

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Refractory SE

• SE refractory to benzos, phts, phenobarb,
  valproate
• Propofol, pentobarb useful third line agents
• Midazolam infusion also useful
• Respiratory depression, BP
• Must control airway, get EEG

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IV Propofol

• Likely GABA mechanism
• Provides burst suppression
• 2 mg/kg loading dose
• Hypotension, resp depression, acidosis
• Easily reversed

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IV Pentobarbital

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

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ED Treatment Protocol

• Have AEDs easily available
• Rapid sequential AED use
• Maximize infusion rate
• Maximize mg/kg dosing
• Benzos, phenytoins, phenobarbital, valproate

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No IV Access

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

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Special Populations

• Drug and alcohol-related seizures
• Acute CVA
• Post-traumatic
• Pregnancy
• Pediatrics
• Elderly
• Psychogenic seizures

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Drug-related Sz

• Stimulants, anti-depressants, theophylline and
  cocaine commonly can cause sz
• Most sz treated with benzos
• Phenytoin less useful

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Drug-related Sz Rx

• INH Blocks GABA production
• Vit B6, pyridoxine
• 5 gr IVP x 6, match ingestion gr
• Theophylline eliminate with hemodialysis,
  hemoperfusion
• Tricyclics, cocaine benzos,?? utility of other
  drugs

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EtOH-related Seizures

• Occur 12 hrs p last drink
• Lorazepam optimal Rx for sz
• Lorazepam in DTs and sz prevention
• Phenytoin ?? sz flurries, SE

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Seizures in Acute CVA

• Seizures can occur in stroke
• Consider prophylaxis with elderly, large
  hemorrhage, anterior CVA location

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Post-traumatic Seizures

• High-risk populations exist
• Early prophylaxis stops early sz, not late sz
  onset
• Phenytoins, valproate

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Seizures in Pregnancy

• Seizures related to changing AED levels and
  eclampsia
• Benzos may be useful initially
• Magnesium 4-6 g load, 1-2 g/hr
• Respiratory depression, BP

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Pediatric Seizures

• Peds sz, SE in kids 0-3 yrs
• Common ED problem
• 80 are febrile sz
• CNS abnormalities afebrile sz
• Cocaine, hyponatremia, meningitis
• Outcome good, CNS plastic

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Febrile Seizures

• 6 months to 5 years
• Up to 50 repeat febrile sz
• Increased risk if age lt 1 yr
• No increased epilepsy risk
• Complex focal, gt 15 min duration, flurry of sz

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Febrile Seizure ED Rx

• Limited need for LP
• Sz as sole manifestation of meningitis not seen
• HIB meningitis rare
• Treat bacteremia (WBC gt 15k)
• CBC, blood cx, ceftriaxone

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Other Pediatric Sz Types

• Neonatal seizures
• Benign childhood epilepsy (Rolandic)
• Infantile spasms (West syndrome)
• Lennox-Gastaut syndrome
• Atonic seizures
• Juvenile myoclonic epilepsy (JME)

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Juvenile Myoclonic Epilepsy

• Common in teens, young adults
• Etiology of generalized TC seizures
• History of staring spells, AM clumsiness,
  myoclonus
• Sleep deprivation, EtOH precipitants
• Valproate may be best acute Rx

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Seizures in the Elderly

• AMS non-convulsive SE
• Drug-drug interactions
• CVD, tumor, toxicities
• Caution for hypotension, cardiac dysrhythmias, IV
  AED extravasation

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Psychogenic Sz

• Functional sz, not neurogenic
• Conversion disorder, not faking it
• Seen in 20 of epilepsy pts
• Neurogenic sz in up to 60 of psychogenic sz pts
  treat first!
• Characteristic mvmts noted

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EMS Seizure Rx

• Sz cause recurrent EMS need
• ALS care for CNS findings, unstable, high risk
• Low risk fractures (BB/collar)
• IV, PR diazepam
• IM midazolam

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Research in Sz, SE

• Treiman D VA Coop study
• Alldredge B PHTSE
• Huff S ED Sz epidemiology
• EFA Working Group (JAMA)
• Hampers L Febrile sz ED Rx

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EFA Guidelines

• Protocol ABCs, know drugs, adequate doses
• Benzodiazepines, phenytoins, phenobarb/valproate
• Midazolam, propofol, pentobarb
• Specify general timelines

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SE Rx Timeline

• 0-30 min ABCs, benzos
• 30-45 min Phenytoins
• 45-75 min Phenobarb/valproate
• 75 min Refractory SE Rx
• 90-150 min CT, EEG, ICU/OR

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ACEP CPC Questions

• Clinical Policy Committee
• Written guidelines
• Clinically relevant questions
• Role of oral loading
• Subtle SE, EEG use
• Post-benzo AED therapy in SE
• New onset seizure ED Rx

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Sz, SE Conclusions

• Sz, SE medical emergencies
• Early Rx is critical
• Many Rx options exist
• Maximize ED Rx
• Have a plan
• Have meds readily available
• Use EEG when indicated

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Slide Content

• Slides on FERNE website
• EM physicians, neuro emergencies
• www.FERNE.org
• Look for button on main page
• 2001 ICEP Seizure Lecture

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FERNE Sz Symposium

• Tuesday October 16, 2001
• 400 to 600 pm
• U of Chicago Gleacher Center
• Clinical Issues in ED Seizure Rx
• Register online at www.FERNE.org