Transcript Management of the Septic Patient in the Emergency Department

Status Epilepticus
Appendix 3
Debriefing Materials for
Simulation Exercise
Status Epilepticus
• Clinical or electrographic seizures
lasting more than 30 min without full
recovery of consciousness between
seizures
Impending Status Epilepticus
• Continuous or intermittent seizures
lasting more than 5 min without full
recovery of consciousness between
seizures
• Treat as aggressively as confirmed
status epilepticus
Subtle Status Epilepticus
• Both the motor and EEG expression
of seizures become less florid,
however prognosis and therapeutic
implications remain the same
Spectrum of Disease
Impending Status
Epilepticus
Convulsive SE
Subtle SE
Nonconvulsive
SE
Lancet Neurol 2006; 5: 252
Benzodiazepines
• Diazepam: enters CNS in 10 sec, lasts 2030 min; rectal gel (10mg) effective in 7590% of cases
• Lorazepam: enters CNS in 2-3 mins; lasts
2-3 hours
• Midazolam: 0.15 mg/kg load then drip @118 mic/kg/min iv, im, sl
Which Benzo Do I Use?
• Lorazepam is preferred due to long activity
• In the absence of intravenous access,
diazepam can be given intramuscularly
until access is established
• Midazolam is generally reserved for
refractory status epelipticus
Dilantin
• Initiate intravenous load on presentation to
ED for impending or established status
epilepticus
• Should I use phenytoin or fosphenytoin?
Dilantin
• Phenytoin:
– 20 mg/kg iv load @ 50 mg.min
– onset in 20-30 mins but load is slow
– low pH is damaging to soft tissue if IV
infiltrates
• Fosphenytoin:
– 20 DPH equivalents iv or im
– 8 mins for effect
– Preferred for rapid load
Refractory Seizures
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Barbiturates
Propofol drip
Midazolam drip
Valproic acid
Ketamine (only if CT head is negative for
mass or hydocephalous)
1.
2.
ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Seizures. Critical Issues
in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With
Seizures. Ann Emerg Med. 2004;43:605-625.
Chen, Wasterlain. Status epilepticus: pathophysiology and management in adults. Lancet Neurol 2006;
5: 246–56.
Consider Other Therapies
• Eclampsia – Magnesium*
– 6g loading dose over 15-20 minutes
– 2g/h continuous infusion
• INH overdose – pyridoxine
– gram for gram dosing of pyridoxine
– 5g iv when dose of INH unknown
*Sibai. Diagnosis, prevention and management of eclampsia. Obstetrics & Gyn 2005;105(2):402-10.
Airway
• Induction with
– Etomidate may lower seizure threshold*
– Propofol or barbiturates may be better
• Paralysis is acceptable, but should
obtain bedside EEG if long term
paralysis initiated
* Khalid, et al. J Electroconvulsive Therapy. 2006; 22:184-8.
Post Intubation Management
• Consider higher ventilatory rates to
compensate for lactic acidosis from
convulsions
• Paralysis may be helpful to reduce
acidosis, but must be used with
bedside EEG
Hemodynamic Support
• Often necessary in refractory status
epilepticus requiring barbiturates or
propofol.
– Intravenous fluids
– Vasopressors as needed
Isoniazid Toxicity
Symptoms
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Nausea
Vomiting
Dizziness
Light sensitiviy
Seizures
Hyperpyrexia
Hypotension
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Tachycardia
Urinary retention
Hemorrhage
Ataxia
Slurred speech
Stupor
Hepatitis
Diagnosis
• Clinical diagnosis
• Should have an increased level of
suspicion in refractory seizure
• Bystander and EMS history very important
Laboratory
• Anion gap acidosis
• Elevated liver enzymes
Treatment
• Support ABC’s
• Activated charcoal
• Treat seizures aggressively
Seizures
• INH causes depletion of inhibitory
neurotransmitter in brain (GABA)
• Pyridoxine serves as cofactor to produce
more GABA
• Standard anticonvulsants are
ineffective
• Gram for gram dosing of pyridoxine
– 5g iv when dose of INH unknown