Today’s Morning Report is presented by Dr. Brown!

 

Recommendations for Management of First-time Seizure and Status Epilepticus

1. Are we mandated to report to DMV?

–       no, but other states (CA, DE, NV, NJ, PA) have mandatory reporting laws.

 

2. Which AED’s can you measure blood levels?

–       phenytoin, carbamazepine, phenobarbital, and valproic acid

–       levetiracetam levels cannot be checked in the ED

 

3. What are effective dosing strategies for preventing seizure recurrence in a patient found to have subtherapeutic serum phenytoin level?

–       Level C recommendations:

  • Give IV or oral loading dose of phenytoin
  • Give IV or IM fosphenytoin

–       There are no RCT comparing IV vs. PO loading doses

 

4. How should AED’s be loaded?

–       Phenytoin can be loaded orally if given in appropriate doses (19mg/kg in men and 23mg/kg in women)

–       Fosphenytoin 15-20 PE/KG IV or IM

–       Valproic acid 20mg/kg

–       Levetiracetam, cannot be readily checked, but because of wide therapeutic index, considered safe to give w/o knowing compliance

 

5. Ecclampsia: new onset GCT seizure during pregnancy or up to 4 weeks post partum

–       Mg loading dose of 4-6g over 20 minutes with maintenance infusion of 1-2g/hour

  • If continue to have seizure activity, give benzos

 

6. Trauma: 4% of epilepsy is caused by trauma.  The risk of post-traumatic seizures is directly related to the severity of injury, but is not affected by early use of AED.

 

Status epilepticus: continuous or intermittent seizures for more than 5 minutes without recovery of consciousness

–       after 5 minutes, seizures become:

  • less likely to spontaneously terminate
  • less likely to be controlled by an AED
  • more likely to cause neuronal damage.

–       RSI: give short-acting paralytic to prevent masking ongoing seizure activity

–       Benzodiazepines are first line treatment

  • 2mg IV every 2 minutes x 5 doses (10mg total)

 

Fosphenytoin is second-line treatment (lacks propylene glycol diluent)

–       20mg/kg, another 10mg/kg bolus can be considered

 

*** failure to respond to benzodiazepine and phenytoin defines refractory status epilepticus.  9-30% of status becomes refractory, and mortality jumps to 50%.

mr11012013p1

 

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Jay Khadpe MD

  • Editor in Chief of "The Original Kings of County"
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

Categories: Morning Report

Jay Khadpe MD

  • Editor in Chief of “The Original Kings of County”
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

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