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How to manage the seizing patient

How to manage the seizing patient. Jason Haag Intern Conference. Case. 34 y.o. with h/o seizure disorder presents to ED with increased seizure frequency. He states he’s had 4 tonic-clonic seizures over the past 24 hours.

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How to manage the seizing patient

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  1. How to manage the seizing patient Jason Haag Intern Conference

  2. Case • 34 y.o. with h/o seizure disorder presents to ED with increased seizure frequency. He states he’s had 4 tonic-clonic seizures over the past 24 hours. • He has a 6 year history of epilepsy treated with carbamazapine 400 mg po bid. He notes increased nausea, vomitting, and diarrhea over the last week which made him unable to take his meds. • No fever, new medications, trauma or alcohol abuse

  3. Case • Physical Exam • Mildly low BP (100/60) • Lethargic, but able to follow commands • Lateral tongue bites noted • Neuro exam unremarkable • Labs • WBC 12, Na 132 • Otherwise wnl

  4. Case • As you finish your exam the patient begins to have a tonic-clonic seizure lasting 2 minutes • What do you do right now???? • What are you thinking is causing the seizure??? • Work up???

  5. Epilepsy • What is it? • Tendency to have recurrent unprovoked seizures (2 or more) • How common is it? • Common, about 2.5 million people in US • Common presentation complaints • New seizure or increased frequency of seizures

  6. Epilepsy • Types of seizures • Localization related seizures • Partial or focal • Start in one part of brain and may spread • Simple or complex • Simple = normal awareness • Complex = impairied awareness • May progress to generalized seizure • Generalized seizures • Involve both hemispheres of the brain at onset

  7. Epilepsy • Status Epilepticus • 5 minutes of persistent seizures • Or a series of recurrent seizures without a return to full consciousness between • Does not have to be tonic-clonic seizure • Nonconvulsant states can be in status • i.e. absence, complex partial seizures

  8. 1st Seizure Evaluation • Seizure causes • Head trauma • Brain tumor • CVA • Encephalitis/Meningitis • Hypoglycemia/nonketotic hyperglycemia (HONK) • Hyponatremia/Hypernatremia • Hypocalcemia, hypomagnesium • Uremia • Hyperthyroidism • Anoxia • Etoh/benzo withdrawal

  9. 1st Seizure Evaluation • Seizure imitators • Syncope • Psych d/o • Sleep d/o (narcolepsy) • Migraine • TIAs

  10. 1st Seizure Evaluation • Work up • Chemistry, thyroid function • Prolactin (?) • LP • If concerned about infection • Neuro imaging • EEG • Often normal or nondiagnostic

  11. Acute Management of Seizures • Goals • Prevent aspiration/trauma • Terminate seizure • Prevent future seizures

  12. Acute Management of Seizures • What to do • Place patient in lateral decubitus position with head elevated at 3o degrees (lessen risk of aspiration) • Give oxygen • Accucheck • If low 1 amp D50 • If h/o EtOH use give thiamine first • Lorazepam .1 mg/kg total given in 2 mg increments • May repeat every minute • Can be given IV or IM, though better IV • Can give rectally, but here we just don’t need to

  13. Acute Management of Seizures • Can load with IV phenytoin 15 mg/kg • IV infusion rate 50 mg/min • Watch for hypotension and arrythmias • If allergic, can load with phenobarbital, valproate, levetiracetam

  14. Status Epilepticus • If seizures persist consider • Intubation • Lorazepam gtt • .1 mg/kg/hr • Can use propofol gtt • Watch for complications of status epilepicus • Lactic acidosis, hyperreflexia, electrolyte abnomalities, rhabdomyolysis and renal failure

  15. Antiepileptic Drug • Decision typically made by Neurologist • Know common drugs and side effects

  16. Case • What do you do right now???? • Lorazepam IV +/- antiepletic • What are you thinking is causing the seizure??? • Electrolytes, thyroid function wnl • Carbamazapine level subtherapeutic • Work up??? • Likely does not need imaging (h/o seizure d/o) or LP

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