Which intravenous drug Will a nurse anticipate might be used for a patient experiencing status epilepticus?
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Ep 133 Emergency Management of Status Epilepticus
Among the presentations seen in the ED, few command the same respect as status epilepticus. It is, in itself, both a diagnostic dilemma and, at times, a therapeutic nightmare. There’s a reason it’s the very first domino to fall in the dreaded sequence “seizure, coma, death”. Status epilepticus can be nuanced to manage. Sure, most seizures self-abort or love an IV dose of lorazepam, but ask anyone who’s been down the propofol route, and they’re not likely to have forgotten the time they stared down a patient who just…would…not….stop. Dr. Paul Koblicand Dr. Aylin Reid return for a deep dive into the nuances of ED management of status epilepticus, and suggest a treatment algorithm based on the latest evidence and consensus opinion… Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Lorrain Lau & Winny Li, edited by Anton Helman & Paul Koblic December, 2019 Cite this podcast as: Helman, A. Koblic, P. Reid, A. Kovacs, G. Emergency Management of Status Epilepticus. Emergency Medicine Cases. December, 2019. https://emergencymedicinecases.com/status-epilepticus. Accessed [date]
Status epilepticus definition
Most seizures resolve spontaneously in 1-3 minutes. However, by the time the seizure is identified, physician is notified and attends to the patient, IV access is obtained, drugs are drawn up and given, most actively seizing patients who have not already stopped seizing will be in status epilepticus. Initial ED management of status epilepticus
Note that patients who cease to display tonic clonic seizure may continue to have non-convulsive status epilepticus that can only be detected on EEG. First line treatment in adult status epilepticus: BenzodiazepinesChoose one of the following first line options (Level A evidence):
If neither of these 2 options are available, choose one of the following:
In patients without established IV access, IM midazolam is preferred. However, the most important determinant of benzodiazepine efficacy in terminating seizures is time to administration rather than choice of benzodiazepine or the choice of route. The longer a patient seizes, the more refractory to medications they become.
Should benzodiazepines be administered in seizures < 5 minutes? Some experts recommend waiting 5 minutes before administering the first anti-seizure medication and giving them slowly over a few minutes because the majority of seizures resolve spontaneously in <5 mins and these medications at therapeutic doses have significant side effects. However, apnea and hypotension are more common with ongoing seizure activity. Aborting the seizure results in less respiratory depression, despite the higher benzodiazepine dose. Our experts recommend not waiting 5 minutes before giving the first dose of benzodiazepine, and to give it IV push ideally. In reality, the vast majority of patients who seize in the ED – by the time we draw up the first medication and are actually giving it, several minutes have lapsed and the patient is likely to be in status epilepticus or nearing status epilepticus.Bottom line: treat seizures early, IV push with adequate doses of benzodiazepines
Special Consideration: Alcohol-withdrawal Seizure In alcohol-withdrawal seizures and status epilepticus, benzodiazepines are also considered first line. While phenobarbital has been suggested as an effective first line medication for alcohol withdrawal without seizure, there is no evidence that phenobarbital alone is superior to benzodiazepines for alcohol withdrawal seizures/status epilepticus. Learn more about alcohol-withdrawal seizures at Episode 87: Alcohol Withdrawal and Delirium Tremens: Diagnosis and Management Second line treatment for status epilepticusIf benzodiazepines fail and the patient is still seizing, start second line medications. Status epilepticus can progress into non-convulsive status epilepticus and it can be difficult to diagnose without EEG monitoring. In the ED, observe for a progressive return to baseline within 60 minutes. If observed seizing cesses but there is no return to near-baseline mental status within 60 minutes, there should be concern for non-convulsive status epilepticus. For patients requiring ongoing infusions of sedating medication or are have received a paralytic, non-convulsive status can only be ruled out by EEG. Bottom line is if there are ongoing subtle motor movements or no progression towards baseline mental status, err on the side of caution and continue to treat for status epilepticus until EEG monitoring is available. Choose one of the following equivalent second line options as a single dose:
Update 2019: ESETT Trial In adults and children with persistent benzodiazepine refractory generalized convulsive SE, it was found that there was no difference between the use of levetiracetam, fosphenytoin and valproate in seizure cessation and improved alertness by 60 minutes.
Phenytoin vs FosphenytoinThe efficacy of phenytoin and fosphenytoin for time to seizure cessation are comparable, however there are theoretical reasons why fosphenytoin might be preferred:
Phenytoin and fosphenytoin have sodium channel blockade effects, which is similar to the mechanism of action of certain toxidromes such as TCA and cocaine overdose. The additional Na channel blockade of phenytoin/fosphenytoin can result in cardiac dysrhythmias/CV collapse. These drugs should generally be avoided in toxicological causes of seizure for this reason. If a patient has a known seizure disorder and is already taking phenytoin, our experts recommend choosing a different medication. Drug levels take time to result and if they are already therapeutic on phenytoin, then it is unlikely that loading them with more would be unlikely to be efficacious and likely to increase the incidence of cardiotoxicity.
Use of propofol as second line agent in status epilepticusThere is emerging literature to support the use of propofol as a second line anti-epileptic in tandem with traditional second line agents but controlled data is limited. The recommended dose is propofol IV bolus 2 mg/kg, followed by 50-80 mcg/kg/min (3-5 mg/kg/hr) infusion. All second line medications recommended by the guidelines take time to draw up and time to infuse, therefore taking a long time until cessation of seizure (examples are ConSEPT and EcLIPSE trials in children showing 30-45min until cessation of seizure). Propofol is readily available, familiar, can be given quickly, and has a rapid onset of action. In addition, it is a safe option in the suspected toxicological case. Update 2019: A study by Burman in 2019 of pediatric patients in South Africa showed that phenobarbital at 20mg/kg +/- repeat 10mg/kg x2 was superior to 86% success (10min to cease) vs 46% (28min to cease) with phenytoin NNT = 2.5 56% respiratory depression vs 70% respiratory depression Refractory status epilepticusIf the patient continues to seize after first and second line treatment, they are in refractory status epilepticus. Therapeutic options include midazolam infusion, ketamine or another second line anti-epileptic medication not already used. Medication options in refractory status epilepticus· Propofol 2-5 mg/kg IV, then infusion of 50-80 mcg/kg/min (3-5 mg/kg/hr) · Midazolam 0.2 mg/kg IV, then infusion of 0.05-2mg/kg/hr · Ketamine 0.5-3 mg/kg IV, then infusion of 0.3-4mg/kg/hr · Lacosamide 400 mg IV over 15min, then maintenance of 200mg q12h PO/IV · Phenobarbital 15-20mg/kg IV at 50-75mg/min · Consider consulting anesthesia for inhaled anesthetics The longer convulsive SE continues, the less convulsive it appears clinically, and continuous EEG monitoring should be instituted as soon as feasible. EM Cases algorithm for ED management of status epilepticusNote correction of Locasamide dose to 400mg IV Dec 2019 Advanced airway management in status epilepticus (Dr. George Kovacs)Why intubate? When to intubate? How to intubate? Preoxygenation Induction agent Propofol IV 1.5-2 mg/kg Have on hand rescue vasopressors as needed. Paralytic: Roc vs Succs Take home points for emergency management of status epilepticus
Learn more about approach to seizures at Episode 132: Emergency Approach to Resolved Seizures References
Now test your knowledge with a quiz. By Anton Helman|2022-06-21T14:57:06-04:00December 17th, 2019|Categories: EM Cases, Emergency Medicine, Episodes, Medical Specialty, Neurology, Resuscitation|Tags: Dr. Aylin Reid, Dr. Paul Koblic, leviteracetam, lorazepam, seizure|3 Comments Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases. Related Posts3 Comments
What drug is IV used for status epilepticus?Initial treatment of early status epilepticus (SE) with intravenous lorazepam or intramuscular midazolam is able to control seizures in 63–73 %; buccal midazolam may be an alternative whenever intravenous or intramuscular application of other benzodiazepines is not possible.
What is the drug most used for status epilepticus?Early status epilepticus: first-line treatment
The first-line treatment for early SE mainly comprises the administration of benzodiazepines, the most frequently used of which include diazepam, lorazepam, and midazolam.
What drugs can cause status epilepticus?In therapeutic practice, SE is most commonly seen in association with antibiotics (cephalosporins, quinolones, and some others) and immunotherapies/chemotherapies, the latter often in the context of a reversible encephalopathy syndrome.
What is status epilepticus treatment?How is status epilepticus treated? The healthcare provider will want to end the seizure as quickly as possible and treat any underlying problems that are causing it. You may receive oxygen, have blood tests, and an intravenous (IV) line. You may be given glucose (sugar) if low blood sugar may be causing the seizure.
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