Seizure and Status Epilepticus in Adults

More new content? Christmas came a little late this year, but here you go:  A great post by regular contributor Nick Mancuso on Seizure and Status Epilepticus in adults:

Approach to Seizure and Status Epilepticus in Adults

Seizure Causes/Ddx

VITAMINS

-Vascular (Stroke , AV-malformation )
-Infection (Meningitis, abscess, encephalitis )
-Trauma
-Autoimmune (CNS vasculitis)
-Metabolic (HypoNa , hypoCa , hypoMg , hypoglycemia, hypoxia, delirium tremens, drug OD\withdrawal )
-Idiopathic
-Neoplasm
-pSychiatric

 

Determine Type

See “Discussion” below

Treatment

Check ABC’s, and continue to check as well as vitals, as these drugs induce apnea, long lasting seizures effect the body as seen in Table 1

First Line Benzos: 2mg IV lorazepam most common, x5 (10mg max)

Second Line if 1st fails: fosphenytoin/phenytoin 15-20mg/kg loading, 4-6mg/kg/day maintenance

Third line if 1 and 2 fail to control seizure: In “refractory SE” mortality jumps. Grey zone as to which choice. Secure airway then consider:

  • Barbituates: phenobarbitol 20 mg/kg, but can be given up to 30 mg/kg for refractory seizures
  • propofol
  • others choices: midazolam, valproic acid, or Levetiracetam

Discussion:

Quick- an adult patient rolls in after his wife called 911. She walked into the living room and he was on the floor “shaking, covered in sweat, and wet his pants.” He looks fine now on the stretcher, as you work through the neuro exam in front of the neuro resident, he seizes again. The resident asks you “what are we going to do to help this guy?” as the wife, nurse, nurse tech, and EM resident are staring at you.

Luckily, you took a quick focused history and physical, unlike your meticulous, these fake patients are stupid, but I’m so smart let me recite the anti-seizure list of meds, second year self. You know his first seizure was his first ever, lasted ~5min, and was 35min ago, so you tell your audience the plan.

Hx: It’s important to ask if this is the pts first episode, if not how often do they seize, do they take their meds, when’s the last time the meds were increased or changed, any new meds of any kind begun recently are good questions to ask. If it is the 1st time, ask about possible causes such as the VITAMINS mneumonic, and then screen for uremia, hypoglycemia, drug intoxications, and electrolyte disorders in patients with first seizure who present to the emergency department. Ask a witness to describe the time frame and what the seizure looked like to help determine type.

Types: Focal include simple, complex, and generalized. Clinical diagnosis is difficult and electroencephalographic (EEG) and/or MRI may likely be needed. A defining element of simple focal seizures is a seizure with preserved consciousness. Impaired/altered consciousness during a complex focal seizure, a simple way is to ask the pt if they remember it. Secondary generalized seizures can begin with an aura that evolves into a complex focal seizure and then into a generalized tonic-clonic seizure, aura may not be present.

Generalized seizures include 6 categories, absence seizures, myoclonic seizures, clonic seizures, tonic seizures, Primary generalized tonic-clonic seizures, atonic seizures. For boards, absence are brief episodes of impaired consciousness with no aura or postictal confusion, consists of 3-Hz generalized spike-and–slow wave complexes. Tonic-clonic seizures are aka grand mal seizures. They consist of several motor behaviors, including tonic extension of the extremities lasting for few seconds followed by clonic rhythmic movements and prolonged postictal confusion. On evaluation, the only behavioral difference between these seizures and secondary generalized tonic-clonic seizures is that these seizures lack an aura1. Atonic seizures are also called “drop attacks, are a loss postural tone and result in injuries.

Long term Treatment/Meds

Generally,  treatment with an anticonvulsant is recommended after the second unprovoked seizure because the patient is at increased risk for additional seizure. Treatment is generally not indicated in patients with a single unprovoked seizure, or those with a provoked seizure.  After the 1st onset of seizure, the likelihood of another is estimated at 20-65% or higher depeding on the source2.  However, long term complications, remission rates, and mortality are unchanged whether the patient is begun on an antiepileptic drug after the first or second seizure.

Treatment is usually monotherapy with an AED.  No single AED is best in terms of treatment or side effect profile, and may differ in efficacy and tolerance from patient to patient.  However, least one large trial for initial monotherapy treatment of epilipsy (the SANAD trial) has shown lamotrigine to be a good initial choice for partial seizures, and valproate to be a good initial choice for generalized seizures.

Emergency treatment of acute seizures and status epilepticus

Table 1

Systemic physiology, metabolic, as well as central changes, and derangements during prolonged seizures

< 30 mins
(phase I)
⩾ 30 mins
(phase II)
Hours (refractory)
Systemic physiology
Blood pressure Increase Decrease Hypotension
Arterial oxygen Decrease Decrease Hypoxaemia
Arterial carbon dioxide Increase Variable Hypercapnia
Lung fluid Increase Increase Pulmonary oedema
Autonomic activity Increase Increase Arrhythmias
Temperature Increase by 1°C Increase by 2°C Fever, hyperpyrexia
Metabolic (serum)
pH Decrease Variable Acidosis
Lactate Increase Increase Lactic acidosis
Glucose Increase Normal or raised Hypoglycaemia
Potassium Increase or normal Increase Hyperkalaemia
Creatine phosphokinase Normal Increase Renal failure
Central
Cerebral blood flow Increase 900% Increase 200% Cerebral oedema
Cerebral oxygen consumption Increase 300% Increase 300% Cerebral ischaemia
Cerebral energy state Compensated Failing Deficit, ischaemia

Arch Dis Child1998;79:78-83

Contributor: Nick Mancuso

References

1  Ko David Y, MD Epilepsy and Seizures Treatment & Management

2  Pillow. M Tyson. MD Seizure Assessment in the Emergency Department. http://emedicine.medscape.com/article/1609294-overview#a11

Chapman MG, Smith M, Hirsch NP Status epilepticus  Anaesthesia. 2001 Jul;56(7):648-59.

Nikson, Chris. Seizure. http://lifeinthefastlane.com/

Pillow, M. Tyson, MD and Nikita Malani Focus On: Best Practices for Seizure Management in the Emergency Department. American College of Emergency Physicians Publications. http://www.acep.org/

Tasker Robert C. Emergency treatment of acute seizures and status epilepticus. Arch Dis Child1998;79:78-83http://adc.bmj.com/content/79/1/78.full

Marson AG, et al.  The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial.  Lancet. 2007;369(9566):1016.

 

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