Status Epilepticus

1. Status Epilepticus Appendix 3 Debriefing Materials for Simulation Exercise

2. Status Epilepticus • Clinical or electrographic seizures lasting more than 30 min without full recovery of consciousness between seizures

3. 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

4. Subtle Status Epilepticus • Both the motor and EEG expression of seizures become less florid, however prognosis and therapeutic implications remain the same

5. Spectrum of Disease Impending Status Epilepticus Convulsive SE Subtle SE Nonconvulsive SE

6. Lancet Neurol 2006; 5: 252

7. Benzodiazepines • Diazepam: enters CNS in 10 sec, lasts 20-30 min; rectal gel (10mg) effective in 75-90% of cases • Lorazepam: enters CNS in 2-3 mins; lasts 2-3 hours • Midazolam: 0.15 mg/kg load then drip @1-18 mic/kg/min iv, im, sl

8. 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

9. Dilantin • Initiate intravenous load on presentation to ED for impending or established status epilepticus • Should I use phenytoin or fosphenytoin?

10. 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

11. Refractory Seizures • Barbiturates • Propofol drip • Midazolam drip • Valproic acid • Ketamine (only if CT head is negative for mass or hydocephalous) • 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.

12. 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.

13. 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.

14. 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

15. Hemodynamic Support • Often necessary in refractory status epilepticus requiring barbiturates or propofol. • Intravenous fluids • Vasopressors as needed

16. Isoniazid Toxicity

17. Nausea Vomiting Dizziness Light sensitiviy Seizures Hyperpyrexia Hypotension Tachycardia Urinary retention Hemorrhage Ataxia Slurred speech Stupor Hepatitis Symptoms

18. Diagnosis • Clinical diagnosis • Should have an increased level of suspicion in refractory seizure • Bystander and EMS history very important

19. Laboratory • Anion gap acidosis • Elevated liver enzymes

20. Treatment • Support ABC’s • Activated charcoal • Treat seizures aggressively

21. 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