Morning Report: 11/1/2013

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%.

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