Seizure Management in the ED: Putting It All Together

Andy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of Medicine

New York, New York

Patient who has seized and returned to baseline

First time

yes no

Consider need for CBC, LFTs, Ca, Mg, PO4, drug of abusescreen alcohol level

same as past events

noyes

check AED levelassess for factors that lower seizure threshold

HIV + ORImmunocompromised

CT / LP

Focal neurologic exam

yes no

CT in EDCT in ED OR Arrange CT as an outpatient

Obtain electrolytes, glucosepregnancy test in woman

Assess for drug use head trauma, medical illness medications, pregnancy, hypoglycemia, focal neuro exam

Approach to pt who has sz and returned to baseline

B

CB

C

BB If on phenytoin

and subtherapuetic load with IV, POo, IM

C

Discharge for outpt workup / Do not start AEDC

Patient seizing

Assess and secure the ABCs; Protect the patient from harm; Check glucose and give dextrose if <80 Perform a physical assessment; Monitor vital signs, ECG, pulse oximetry

Assess need for:AntibioticsCharcoalToxin specific therapy (eg B6, HCO3)

Seizure stopsSee pathway I

Seizures continue

Observe and prepare for a second event

Send blood for: pregnancy test, CBC, electrolytes AED levelsConsider sending blood for: Mg, Ca, PO4, LFTs, ETOH, toxicology screen / levels

Lorazepam, 2 mg / min to a max of 10 mg(.1 mg/kg in children)

sz# stops sz continues

Phenytoin 18 mg / kg at 25-50 mg / min##orFosphenytoin 18 PE */ kg at 150 mg / min

sz stops sz continues

Repeat phenytoin or fosphenytoin at 1/2 the initial doseor phenobarbital 20 mg / kg at 100 mg / min

sz stops sz continues

Clinical pathway for status epilepticus

C

C

C

Observe Prepare for another seizure Pentobarbital,** 3-5 mg / kg at 25 mg / min then drip at .5 - 3 mg / min

orMidazolam 200 ug / kg bolus then 1-10 ug / kg / minorPropofol 1-2 mg / kg bolus then 2-10 mg/kg/hr

Consider bedside EEG

Reassess patientIntubate at any time airway or breathing is compromisedConsider CT / LP

# sz = seizure

## slower rates for patients with cardiovascular disease. infusion shouldbe through a large bore IV

* PE = phenytoin equivalent

** watch for hypotension and treat initially with fluids; dopamine if needed

AED = antiepileptic drug

C

C

Andy Jagoda, MD

1:00 AM: EMS Called for a Patient Seizing

• Witnesses report that patient druank 3-6 beers

• Patient ingested a “dot” of LSD 2 hours prior to EMS

• Patient asked for “help” then fell to floor seizing

• No history of trauma• No other history available

Andy Jagoda, MD

1:10 AM: EMS Arrived and Called for Activation of Seizure Protocol

• Patient in status epilepticus• BP 130/90, RR 20, P 110• Dextrostix 120• Pulse oximetry 98% saturation• IV access established• Diazepam 5 mg IV Q 5 min to a max

of 20 mg • Estimated ETA: 20 minutes

Andy Jagoda, MD

1:30 AM: Patient Arrived in the ED Seizing

• Diazepam 20 mg given in the field

• BP 130/90, P 110, RR 20, Rectal T 37

• BS and Pulse Ox unchanged

Andy Jagoda, MD

Physical Exam

• Tonic clonic activity

• WDWN: No evidence of immunocompromise

• No signs of trauma

• No signs of intravneous drug use

• Unresponsive to verbal or painful stimuli

Andy Jagoda, MD

Physical Exam

• PERL: Dilated to 8 mm

• Gaze away from the

examiner

• Gag intact

• No incontinence

Andy Jagoda, MD

PHYSICAL EXAM

THE VIDEO

The Results of a Diagnostic Test was

Obtained

Andy Jagoda, MD

Laboratory Tests

• Electrolytes: NA 143, K 4.1, CL 108, HCO3 24

• Alcohol: 120 mg/dl• CPK: 240 ng/mL• Tox Screen for DOA: Normal

Arterial Blood Gas: pH 7.44, pO2 110, pCO2 36, 100% saturation

Andy Jagoda, MD

A Dx of Psychogenic Status Epilepticus was Made

• Patient was given verbal suggestions that the seizures would stop if he concentrated

• While still “seizing” the patient began to cry for help

• Over 10 minutes the “seizures” slowly subsided

Andy Jagoda, MD

Past Medical History• Similar but brief event since age 10

• Focal• Controlled with concentration

• Events always occurred in association with stressful situations

• Emotional and physical abuse as a child• Father beat him • Chained to the bed

• Presently under stress from losing job

Andy Jagoda, MD

The LSD “Trip”

• Recalled initial euphoric feeling

• Recalled floating sensation

• Followed by strong visual distortions

• Remembers becoming panicked that he could not control himself

• Remembers the seizure and all care given

Andy Jagoda, MD

Physical Findings Suggestive of Psychogenic Seizures

• Out of phase movements

• Pelvic thrusting

• Head turning side to side

• Dilated pupils, reactive to light

Andy Jagoda, MD

Howell et al. Pseudostatus epilepticus. Q J Med. 1989;71:507-519

• 40% of patients transferred in “status epilepticus” were in psychogenic status

• Estimated 5% TO 20% of patients referred to epilepsy centers have psychogenic seizures

Andy Jagoda, MD

Criteria for a Conversion Disorder

• Alteration in physical functioning

• Psychological factors involved

• Symptoms are not unders voluntary control

• Symptoms are not explained by a physical disorder

Andy Jagoda, MD

Conclusions

• Management of a patient with a first time seizure is based on a careful neurologic exam, and the results of a chemistry panel, head CT, and EEG

• Oral phenytoin loading provides “therapeutic” serum levels four hours post-load in most cases

• Lorazepam is the best first line treatment for seizures

Andy Jagoda, MD

Conclusions

• In refractory status epilepticus, pentobarbital, midazolam, or propofol are third line agents

• Psychogenic seizures are characterized by out of phase motor activity, forward pelvic thrusting, voluntary eye movements, normal mental status