165. Seizures and Status Epilepticus in Adults

Status: 5 minutes of persistent seizures or >2 recurrent seizures without return to baseline
Non-convulsive Status: prolonged postictal state; odd behaviors (blinking, abnormal eye movements), 14% of convulsive seizures convert to NCSE

1/10 with SE does not survive to hospital discharge.

Causes of Provoked Seizures: Tumor/structural brain lesion, TBI, Alcohol (intoxication/withdrawal), Metabolic, Toxicologic, Pregnancy (eclampsia), Infection, HTN encephalopathy, Heat stroke.

INH OD: Give pyridoxine (mainly board review).
Workup: Sodium, Glucose, Calcium, Pregnancy test. EKG. CT brain with trauma, refractory seizure, antiacogulants, first time seizure. LP (immunocompromise or fever).

Always check glucose.

Decrease time to getting medications on board.

#1. Benzo: Lorazepam 4mg/Diazepam 5mg/Midazolam 10mg – usually 0.1mg/kg except for Diazepam which is 02.mg/kg.

RAMPART: IM Midaz (10mg) vs IV Loraz (4mg): 73.4% vs 63.4%. Time to treatment was 1.2min vs 4.8min.

#2. Phenytoin + Valproic Acid. Fosphenytoin: Loading dose 18-20mg/kg. Must give weight based dose. Valproic is also 20-40mkg/kg.

Usually after first 2 agents, usually refractory – intubate and needs continuous EEG.

#3. The Others (likely intubate).
Keppra: 1500mg loading. Phenobarbital 20mg/kg.
IV Propofol 1-2mg/kg then 1-15mg/kg/h.

#4 Pentobarb. 5mg/kg; likely need pressors.

#5 ??? Ketamine with benzos, Magnesium sulfate, Lacosamide, Hypothermia.

References

Status Epilepticus – Danya Khoujah, The 2015 Crashing Patient Conference 2015 – http://cloud.emedhome.com/cme/cme_45770_hi.mp4?iframe=true&width=920&height=470

165. Seizures and Status Epilepticus in Adults

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