Seizure Management in the ED: Putting It All Together Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai

1. Seizure Management in the ED: Putting It All TogetherAndy Jagoda, MD, FACEPProfessor of Emergency MedicineMount Sinai School of MedicineNew York, New York

2. Approach to pt who has sz and returned to baseline Patient who has seized and returned to baseline First time yes no B same as past events Assess for drug use head trauma, medical illness medications, pregnancy, hypoglycemia, focal neuro exam yes no B C Obtain electrolytes, glucose pregnancy test in woman check AED level assess for factors that lower seizure threshold C Consider need for CBC, LFTs, Ca, Mg, PO4, drug of abuse screen alcohol level C HIV + OR Immunocompromised Focal neurologic exam If on phenytoin and subtherapuetic load with IV, POo, IM B no yes B CT / LP CT in ED OR Arrange CT as an outpatient CT in ED C Discharge for outpt workup / Do not start AED

3. Patient seizing Clinical pathway for status epilepticus 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: Antibiotics Charcoal Toxin specific therapy (eg B6, HCO3) Send blood for: pregnancy test, CBC, electrolytes AED levels Consider sending blood for: Mg, Ca, PO4, LFTs, ETOH, toxicology screen / levels Seizures continue Seizure stops See pathway I C Lorazepam, 2 mg / min to a max of 10 mg (.1 mg/kg in children) sz continues sz# stops C Phenytoin 18 mg / kg at 25-50 mg / min## or Fosphenytoin 18 PE */ kg at 150 mg / min sz stops sz continues C Repeat phenytoin or fosphenytoin at 1/2 the initial dose or phenobarbital 20 mg / kg at 100 mg / min sz stops sz continues Observe and prepare for a second event

4. C Observe Prepare for another seizure Pentobarbital,** 3-5 mg / kg at 25 mg / min then drip at .5 - 3 mg / min or Midazolam 200 ug / kg bolus then 1-10 ug / kg / min or Propofol 1-2 mg / kg bolus then 2-10 mg/kg/hr C Consider bedside EEG Reassess patient Intubate at any time airway or breathing is compromised Consider 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

5. 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

6. 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

7. 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

8. 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

9. Physical Exam • PERL: Dilated to 8 mm • Gaze away from the examiner • Gag intact • No incontinence

10. PHYSICAL EXAMTHE VIDEO

11. The Results of a Diagnostic Test was Obtained

12. 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

13. 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

14. 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

15. 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

16. Physical Findings Suggestive of Psychogenic Seizures • Out of phase movements • Pelvic thrusting • Head turning side to side • Dilated pupils, reactive to light

17. 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

18. 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

19. 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

20. 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