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Optimizing Seizure and SE Patient Management in the Emergency Department

Optimizing Seizure and SE Patient Management in the Emergency Department. Edward P. Sloan, MD, MPH Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL.

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Optimizing Seizure and SE Patient Management in the Emergency Department

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  1. Optimizing Seizure and SE Patient Management in the Emergency Department

  2. Edward P. Sloan, MD, MPHProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

  3. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL

  4. Disclosures • NovoNordisk, King Pharmaceuticals, UCB Pharma Advisory Boards • Eisai Speakers’ Bureau • ACEP Clinical Policies Committee • ACEP Scientific Review Committee • Executive Board, FERNE • FERNE support by Abbott, Eisai, Pfizer, UCB

  5. www.ferne.org

  6. Board Chairman and PresidentFERNEChicago, IL

  7. OverviewMission Statement • Patients with neurological emergencies deserve quality emergency care. • Quality scientific research. • Case-oriented, evidence-based medical education on optimal acute neurological care. • Use of technology to break down space and time barriers. • Advocacy.

  8. www.ferne.org

  9. Today’s Agenda • Present a clinical case • Review seizure and SE clinical data • Discuss ED management • Provide fosphenytoin data • Consider fosphenytoin use • Examine the patient outcome • Close with a bonus case

  10. A Clinical Case

  11. Patient EMS Data • 50?? yo male John Doe • Generalized tonic-clonic seizure • Chicago Fire Department • Diazepam 5 mg IM, 15 mg IV • Seizure continuous for 15 minutes + • EMS to ED • No change in status

  12. Patient Clinical History • Unknown meds • Unknown medical history • Hx Needs surgery next month ?? • EtOH ?? • Does not appear to be homeless • Accucheck 119

  13. ED Presentation • Facial and shoulder twitching R • Pt with gurgling BS • Nasopharyngeal airway • No evidence of trauma or toxicity • IV access in neck • Seizure persists x minutes

  14. Seizure/SE Clinical Data

  15. Sz Epidemiology: • Epilepsy seen in 1/150 people • For each epilepsy pt, 1 ED visit every 4 years • 1-2% of all ED visits • Significant costs

  16. Seizure Mechanism: • Sz = abnormal neuronal discharge with recruitment of otherwise normal neurons • Loss of GABA inhibition

  17. SeizuresSeizure Classification: • Generalized: both cerebral hemispheres • Partial: one cerebral hemisphere (localized)

  18. SeizuresGeneralized Seizures: • Convulsive: tonic-clonic • Non-convulsive: absence

  19. SeizuresGeneralized Seizures: • Primary generalized: starts as tonic-clonic sz • Secondarily generalized: tonic-clonic sz develops from a non-convulsive partial sz, ie aura (common)

  20. SeizuresPartial Seizures: • Simple partial: no impaired consciousness • Complex partial: impaired consciousness

  21. SeizuresSpecific Seizure Types: • Absence: Petit mal • Partial: Jacksonian, focal motor • Complex partial: temporal lobe, psychomotor

  22. SeizuresRecurrent Seizure Risk • 51% recurrence risk • 75% of recurrent sz occur within 2 years of first sz • Only a small % of pts will seize within 24 h • Partial sz, CNS abnormality

  23. Status Epilepticus: • Sz > 5- 10 minutes • Two sz without a lucid interval (Assumes ongoing sz during coma)

  24. Status EpilepticusSE Epidemiology: • Risk of SE: greatest at age extremes (pediatric and geriatric populations) • SE: occurs in setting of new onset sz, acute insult, or chronic epilepsy • 150,000 cases per year

  25. Status EpilepticusSE Classification: • GCSE: (Generalized convulsive SE) with tonic-clonic motor activity • Non-GCSE

  26. Status EpilepticusTwo Non-GCSE Types: • Non-convulsive SE • Absence SE • Complex-partial SE • Subtle SE • Late generalized convulsive SE • Coma, persistent ictal discharge • Very grave prognosis

  27. Seizures/SESystemic Effects: • Hypertension (early) • Hypotension (later) • 49% will have temp > 100.5 F° • Lactic acidosis • Hypercarbia

  28. Seizures/SEPathophysiology: • Glutamate toxic mediator • Necrosis occurs even if systemic problems are treated (HTN, fever, rhabdomyolysis, resp acidosis, hypoxia)

  29. Seizures/SEPathophysiology: • Early compensation for increased CNS metabolic needs • Decompensation at 40-60 minutes, associated with tissue necrosis

  30. Seizures/SE AMS in Seizures: • Mental status should improve by 20-40 minutes • If pt comatose, subtle SE is possible: EEG • Up to 20% of pts in coma are still in SE

  31. Seizures/SE Ongoing SE Effects: • Over 40-60 min, loss of metabolic compensation • With ongoing SE, systemic BP & CBF drop

  32. Status EpilepticusSE Mortality: • SE mortality > 30% when sz longer than 60 minutes • Underlying sz etiology contributes to mortality

  33. Status EpilepticusSubtle SE: • Mortality exceeds 50% • Often after hypoxic insult • Coma • Limited motor activity • Stop the sz, EEG confirm

  34. Status EpilepticusRefractory SE: • No response to first-line drugs (Benzos, phenytoins) • Significant CNS disorders • 6-9% of all SE cases • 20-30% mortality

  35. General ED Management: • ABCs • Glucose, narcan, thiamine • Rapid sequential use of AEDs • Directed evaluation

  36. ED ManagementLab Evaluation: • Key lab abnormality: hypoglycemia, in up to 2% • Directed labs, including anti-epileptic drug levels

  37. ED ManagementLumbar Puncture: • Fever and CSF pleocytosis can occur in SE without meningitis • Use clinical criteria to determine LP need • AMS, immunocompromise, meningismus

  38. ED ManagementCTNeuroimaging: • Req’d in new-onset sz • Useful with focal sz, change in sz type or frequency, co-morbidity • Non-contrast unless mass lesion suspected

  39. New Onset Sz in Pregnancy • 32 year old Hispanic female • 23 weeks pregnant • G3P2 two live births, no complications • New onset seizure at 530 am in bed • Generalized tonic-clonic seizure • Brief, self-limited, no Rx required • EMS to the ED, no seizure recurrence

  40. Focal hemorrhage

  41. New Onset Sz in Pregnancy • Tertiary center diagnosis: cavernoma • Started on an anti-epileptic drug • No immediate need for operative intervention • Will follow as pregnancy progresses

  42. ED ManagementMRINeuroimaging: • Useful with refractory sz • Complements plain CT • Can be done as outpatient

  43. ED ManagementEEG Monitoring: • Use to rule out subtle SE • Two-lead EEG in ED, within 120 minutes • In RSI, prolonged coma, propofol or pentobarbital induced coma

  44. ED ManagementAED loading: • Repeated seizures, high-risk population, significant SE risk • No need to determine level in ED after loading • Oral loading in low risk pts

  45. ED ManagementSE Rx Timeline: • 0-30 min: ABCs, benzos • 30-60 min: Phenytoins • 60-90 min: Levetiracetam, phenobarbital, valproate • 90-120 min: Midazolam, propofol CT, EEG, ICU/OR

  46. Hospital Admission: • Repeated sz, high-risk pt, significant SE risk • Esp if no AED loading • New-onset seizure: admission is preferred (complete w/u, observe)

  47. ED Discharge: • Follow-up & EEG needed, esp if no AED prescribed • Driving documentation is critical. Know state law.

  48. ED Anti-epileptic Drug (AED) Use

  49. Seizure Pharmacotherapy • Benzodiazepines • Phenytoins • Barbiturates • Other agents • levetiracetam • propofol • valproate

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