Which intravenous drug Will a nurse anticipate might be used for a patient experiencing status epilepticus?

Ep 133 Emergency Management of Status Epilepticus

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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. //emergencymedicinecases.com/status-epilepticus. Accessed [date]

Status epilepticus definition

• Continuous seizure lasting > 5 minutes OR
• 2 or more seizures within a 5-minute period without return to neurological baseline in between

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

• Call for help as many steps of the management will occur in parallel.
• ABCDEFG [ABC’s and Don’t Ever Forget the Glucose] – capillary glucose
• Airway: position in lateral decubitus [when/if possible to minimize aspiration risk] or head up with ongoing suction, nasal trumpets, suction
• Attempt IV access and send for VBG, glucose, electrolytes [Na, Ca, Mg], tox screen, BhCG, CK, Cr, lactate
• Consider crystalloid bolus, draw up push dose pressor for prevention/management of potential hypotension
• IV Lorazepam 4mg [repeat once in 4 mins prn] or IM Midazolam 10mg
• If no response to first dose of IV benzodiazepine, start phenytoin/fosphenytoin [avoid in tox], valproate or levetiracetam
• Prepare to intubate via RSI with propofol or “ketofol” and rocuronium [if sugammadex is available or seizure >20-25 mins] or succinylcholine
• Consider immediate life-threats that require immediate treatment with specific antidotes:
  • Vital sign extremes: hypoxemia [O2], hypertensive encephalopathy [labetolol, nitroprusside] and severe hyperthermia [cooling]
  • Metabolic: hypoglycemia [glucose], hyponatremia [hypertonic saline], hypomagnesemia [Mg], hypocalcemia [Ca]
  • Toxicologic: anticholinergics [HCO3], isoniazid [pyridoxine], lipophilic drug overdose [lipid emulsion] etc.
  • Eclampsia: typically > 20 weeks of pregnancy and up to 8 weeks postpartum [IV MgSO4 4-6 g over 15-20 min, then infusion 1-2 g/h]
• CT head to rule out space occupying lesion/ICH +/- LP

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: Benzodiazepines

Choose one of the following first line options [Level A evidence]:

1. Lorazepam IV: 4mg q4 minutes, may repeat once [*often underdosed in observational studies]
2. Midazolam IM: 10 mg IM once [*often underdosed in observational studies]

If neither of these 2 options are available, choose one of the following:

1. Diazepam IV: 0.15 mg/kg
2. Diazepam PR: 0.2 – 0.5 mg/kg, max 20 mg, single dose
3. Phenobarbital IV: 15 mg/kg, single dose
4. Midazolam IN [0.2mg/kg, max 10mg ] or buccal [0.3mg/kg, max 10mg] [Level B evidence]

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.

Pitfalls: In the emergency management of seizures, the biggest pitfalls are underdosing benzodiazepines and dosing too late!

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