Morning Report: Status Epilepticus

Thank you Dr. Kopping for this Morning Report.

Initial treatment goals: As per “expert opinion” and Dr. Kopping’s opinion

ABCs this is EM after all

Vitals, oxygenate, IV, finger stick, fluid resuscitate

Stop the seizure:

Benzo’s (lorazepam (IV) and midazolam(IM) specifically)

-Everyone worried about resp depression with benzos. In other patients, a clear concern

-People with GCSE had less resp depression when given benzos over placebo…so give them

-Lorazepam IVP 0.1mg/kg up to 4mg first dose, midazolam 0.2mg/kg up to 10mg IM, multiple doses

Add an urgent AED with a loading dose IV (Keppra, fosphenytoin, phenobarbital, valproate)

-If you know what previously on, give that

Continuous drip medication (also great if it is sedation while intubated)

-My choices are propofol and versed(with fentanyl for sedation purposes)

-Phenobarb,pentobarb, and thiopental are also available- more BP effects

-Can start continuous AEDs if bolus/loading dose and above are ineffective.

Neuro, ICU, EEG monitoring, find the cause

-Infection, bleeding, mass, hypoxia, hypoglycemia, electrolyte abnormalities can all cause SE, hopefully some are corrected by now

-If concern patient had recent Tb with INH use, will need Vitamin B6, won’t stop without

-Special case with eclampsia, magnesium sulfate (better than AEDs), immediate delivery

Ketamine- some case reports showing efficacy, might be neuroprotective

-A good secondary survey needs to be done to identify possible injuries

-Mortality can be as low as 8% when treated adequately goes up to 45% when insufficiently treated

-Other factors affecting mortality-> etiology of SE, pre-existing conditions, de novo development as inpatient, duration of seizures, older age, focality at beginning

-Don’t forget to think about a nonconvulsive status in your undifferentiated comatose patient, diagnosed on EEG monitoring

-Mortality/morbidity benefits with earlier rather than later diagnosis (just makes sense)

References:

Brophy et al “Guidelines for Evaluation and Management of Status Epilepticus” Neurocrit Care

Tintinalli’s Emergency Medicine Ch 165 http://accessmedicine.mhmedical.com.newproxy.downstate.edu/content.aspx?bookid=348&sectionid=40381644