EMCrit.org

Seizures

Poor man's EEG is pupillary response to light.

Check thyroid, ask about trauma

Syncope can present c twitching

Ictal-retrograde amnesia, incontinence, tongue biting

Postictal (Todd’s) paralysis-as long as 24 hrs

Neurogenic Pulmonary Edema-from sympathetic discharge-often confused c aspiration

Posterior Shoulder Dislocation

CT Scan for 1st time seizure

Prolactin levels will peak at 20 minutes after seizure and return to baseline in60 minutes.

 

 

Loading of Meds

Dilantin

 

Valproate

 

Kepra

 

Carbamazepine

rapid oral loading of carbamazepine (Ann emerg med 2007;50:121)

 

Status Epilepticus

Status-serial seizures without  consciousness or >30 min of continuous activity

 

Treatment

Benzodiazepines are first line therapy

Lorazepam .1 mg/kg given ~2 mg/min will have onset in 3-5 minutes and last hours

Diazepam .2mg/kg given ~ 5mg/min will have onset in ~1 minute but lasts only about ~20 min for antiseizure activity

Midazolam

 


Valproic acid has recently been made available in an
intravenous preparation. The average dose is 10-15 mg/kg
but a 20 mg/kg load has been safely used. Although not
yet approved for this use in the United States, intravenous
valproic acid can successfully treat convulsive status
epilepticus.

 

 

Benzos- Fosphenytoin- Phenobarb- Pentobarb- Isoflurane

Phenobarb 100 mg boluses until seizure stops

Non-convulsive Status is cause of AMS and can continue post seizure, get EEG

Gelastic Seizures from lesions in temporal or hypothalamus.  Differential diagnosis of pathological laughter is also stroke and tumor

 

Seizures can present with peri-ictal (non-convulsive status) and postictal psychosis or behavior change

 

B6 for Isonazid Overdoses 5 grams or more

Patients with strychnine poisoning may develop seizure-like activity yet demonstrate normal mental status

 

get drugs of abuse screen for cocaine and serum for TCA

 

that old lady twitching their finger may still be having tonic/clonic seizure, but they have just fatigued their twitching to the point that only small movement is left.

 

Sinai Protocol

Ativan 4mg x2 Q5 minutes

Fosphenytoin 20 mg/kg IV at 150 mg/min

May give additional 10 mg/kg of Fosphenytoin

or IV Valproate 40 mg/kg over 10 minutes may give additional 20 mg/kg

or IV Midazolam 0.2 mg/kg then repeat 0.2-0.4 mg/kg boluses Q 5 minutes. Max load 2 mg/kg. Then start 0.1 mg/kg/hr; dose range 0.05-2 mg/kg/hr

or IV propofol load 1 mg/kg repeat 1-2 mg/kg Q 3min until seizures stop max load 10 mg/kg. Start at 2 mg/kg/hour dose range 1-15 mg/kg/hr

or Phenobarb 20 mg/kg at 50-100 mg/min

then IV pentobarb 5-10 mg/kg at 50 mg/min repeat 5 mg/kg until seizures stop. rate 1 mg/kg/hr range 0.5-10 mg/kg/hr.

 

 

Fosphenytoin

Fosphenytoin is a phosphate ester of phenytoin that became available in 1995. It has a safety profile that makes it preferable to phenytoin in certain situations

Fosphenytoin has a peak serum level within approximately one of hour of intramuscular administration and at six minutes after intravenous loading. When ordering fosphenytoin, the physician should use the terminology of "phenytoin equivalents" (PE) to avoid confusion. Thus, the routine loading dose is 18 phenytoin-equivalent units/kg. In emergencies, the recommended infusion rate is 150 PE/min—three times that of phenytoin.

Fosphenytoin is water-soluble, obviating the need for the propylene glycol vehicle. It can be given intramuscularly or intravenously with 100% bioavailability. Fosphenytoin is less of a tissue irritant than the phenytoin/propylene glycol preparation, with pruritus and paresthesias the most common side effects. Patients can receive up to 30 cc IM (yes, that’s 30 cc) in either single or multiple sites with minimal local irritation.70 There are minimal cardiotoxic effects though hypotension has been reported with rapid infusions.71 Blood pressure should be carefully monitored, especially in patients with underlying cardiovascular disease. The package insert recommends the use of cardiac monitoring during infusion.

One study showed no cost benefit with fosphenytoin assuming a low complication rate with phenytoin (Pharmacotherapy 20(8):910 August 2000)

 

 

In one study, there was no time benefit to the use of fosphentoin loading, nor were there any adverse effects with phenytoin load. (Neuro Res 24:842, Dec 2002) and another (Annals 2004 43:3, p.399)

 

No adverse drug effects with phenytoin in this study (Academic Emergency Medicine Volume 11, Number 3 244-252)

 

Consider PO loading of phenytoin in patients who seize secondary to non-compliance.

An oral dose of 19 mg/kg in men and 23 mg/kg in women will produce a therapeutic level in the majority of patients by 3-4 hours.146 However, assess these patients carefully for ataxia and dizziness prior to discharge.  Can give whole dose at once, but probably does not load any quicker and higher risk od adverse effects.  Better to load 400 mg/hour to 20 mg/kg.  Should raise levels by 10.

 

Ann Emerg Med. 1987 Apr;16(4):407-12. Related Articles, Links
Single-dose oral phenytoin loading.
Osborn HH, Zisfein J, Sparano R.
A single 18 mg/kg dose of oral phenytoin capsules or suspension (mean dose, 1.3 g) was given to 44 patients with recent seizures and no detectable serum phenytoin level. Mean serum phenytoin levels after loading for patients receiving capsules were 6.8 micrograms/mL at two hours, 9.7 micrograms/mL at three to five hours, 12.3 micrograms/mL at six to ten hours, and 15.1 micrograms/mL at 16 to 24 hours. Mean levels for patients receiving suspension were slightly, but not significantly, lower than for patients receiving capsules. No seizures occurred during an eight-hour observation period after loading. Drug toxicity was minimal. Single-dose, 18 mg/kg oral phenytoin loading provides rapid therapeutic levels and is well tolerated.

 

IV Phenytoin, though it can be given at 50 mg/minute to dose of 20 mg/kg, should actually me 20 mg/minute.  Give above forearm in at least 20G IV.

 

Calculating phenytoin level correction in hypoalbuminemia:

Corrected level= Measured phenytoin level /[(albumin x 0.2) + 0.1]

In renal failure: CrCL < 20

Corrected level= Measured phenytoin level /[(albumin x 0.1) + 0.1]

 

Sodium Valproate

The recent availability of a parenteral formulation of sodium valproate

(15–20 mg kg−1 loading dose and then 3–6 mg kg−1 min−1 thereafter)

has renewed interest in this agent for the control of SE.
 

Propofol

Modulates GABA-α receptors at a site different from that targeted by benzodiazepines (BZDs) and barbiturates (Epilepsia 2004;45(7):757)
Start with 1 mg/kg slow bolus, may repeat in 5 minutes once. Maintenance 2-4/mg/hr titrated between 1 and 15 mg/kg/hr. Worked in ~2 minutes average in incredibly tiny study (Epilepsia 1998;39(10:18)

 

 

Valproate and tegratol can both cause thrombocytopenia

 

To load depakote, give twice normal dose or 500 mg of depakene

 

To boost phenobarb, give 100 mg PO

Non-Convulsive Status Epilepticus

Dementia, meningitis, tumor, history of brain disease might be predictors of non-convulsive status (J Neurol Neurosurg Psych 74:189 February 2003)

Psychogenic Seizures

The geotrophic eye test is performed by turning the
patient’s head from side to side and observing the eyes. It
seems that in psychogenic seizures, the patient will always
look away from the examiner, regardless of which way the
head is turned.

Neurocysticercosis

 

EEG

EEG reading rules for non-neurologists: (Crippen)
1) don't even try to read neonatal EEGs, especially in premature babies.
2) for other EEGs, remember that the EEG should be the opposite of the ECG:
   a) the more the EEG looks like VF, the better it is
   b) the more the EEG looks like sinus rhythm, the worse it is.
   c) the more the EEG varies in frequency and amplitude over time, the better it is
   d) focal areas that differ from the rest of the EEG are bad (too slow, or too high or too low in
           amplitude)
   e) sharp stuff is almost always bad except at the vertex when falling asleep
   f) whatever you think looks really bad is probably an artifact
3) all the rest is mere commentary (cf. Hillel)

 

Review Article on cEEG (Neurocrit. Care 2005;2:330–341 and in my desktop box)

Lance-Adams syndrome

Might try levetricatam as piracetam is used in countries that have it. Other thoughts:

 
Pappert EJ, Goetz CG, Vu TQ, Ling ZD, Leurgans S, Raman R, Carvey PM. Animal model of posthypoxic myoclonus: effects of serotonergic antagonists. Neurology. 1999 Jan 1;52(1):16-21

 
Wicklein EM, Schwendemann G. Use of clonazepam and valproate in patients with Lance Adams syndrome.  J R Soc Med. 1993 Oct;86(10):618
 
Tom
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Tom Bleck (tpb9k@virginia.edu) Thomas P. Bleck MD FCCM

 

 

 

 

Dilantin levels are inaccurate 2 hours after IV and 4 hours after IM fosphenytoin

 

Mount Sinai Protocol

 

 

Pseudoseizures

ictal deliberate eye closure is reliable indicator of pseudoseizure


(1) Chung SS, Gerber P, Kirlin KA.  Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures  Neurology  2006;66:1730-1.

 

 

Ketamine for Status

Ketamine

• NMDA receptor antagonist; Barbits/benzos work well early in SE,

not late; Ketamine is opposite

• Loading dose: 1-2 mg/kg IV/1 min

• Maintenance dose: 0.01-0.03 mg/kg/min cIV (adjust with liver

failure)

• Principle: use only together with benzos

• Advantage: neuroprotective, hemodynamic stability

• Disadvantage: prolonged use anecdotally linked to brain atrophy

consistent with animal models of NMDA antagonist-mediated

neurotoxicity, may cause hypertension

• Caution with:

– intracranial mass, TBI, globe injuries, hydrocephalus, elevated ICP

– hypertension, chronic CHF, tachyarrhythmias, MI

– ETOH history

Borris 2000; Mazarati 1998, 1999; Mewasingh 2003