User:Glasszone33/draft article on seizure clinical pathways

Title: Management of seizures in Emergency Department

 * Definition:


 * Status epilepticus (SE) is defined as continuous seizure activity for 30 minutes or longer or occurrence of sequential seizures over a similar period without full recovery of consciousness between seizures. In clinical practice, any seizure lasting more than 5 minutes warrants intervention.
 * Refractory SE is a seizures that does not respond to first-line therapy.

Purpose:

To provide guidelines for a timely, effective management of seizures patients.

Policy:

It is policy of Burjeel Hospital to provide initial assessment and management to patient presenting to ER with seizure activity and definitive management such as hospitalization to ICU.

Procedures:



Ensure airway control. Nasopharyngeal airway placement is sufficient for some patients. Adminster 100% Oxygen by nasal cannula. Prepare for possible endotracheal intubation in the event that anticonvulsants fail to terminate the seizure.



Obtain blood specimens for glucose, electrolytes, magnesium, and calcium determinations; hepatic and renal function tests; and complete blood count; as well as 3–4 tubes of blood for possible toxicology screen or determination of drug levels (including anticonvulsants if patient is known or suspected to be taking them).



Give glucose, 50 mL of 50% solution IV over 5 minutes. If malnutrition is suspected, give thiamine, 100 mg IV, slowly prior to, or at the same time as, glucose.

First-Line Agent

Administer diazepam (0.15 mg/kg) or lorazepam (0.1 mg/kg) IV over 5 minutes. If venous access cannot be obtained, diazepam can be given rectally, endotracheally, or intraosseously, or midazolam, 0.2 mg/kg, can be given intramuscularly. If the seizure continues, administer a second dose of benzodiazepine after 15 minutes.

Second-Line Agent

 PHENYTOIN or FOSPHENYTOIN  If the seizure is ongoing, administer loading dose of Phenytoin (18 to 20 mg/kg at a rate of 1 mg/kg per minute) or Posphenytoin (18 to 20 PE ,phenytoin equivalents,/kg at 150 mg per minute. Never mix phenytoin with a 5% dextrose solution.

Third-Line Agent

If seizure persists administer phenobarbital at a dose of 10–20 mg/kg.Beware of both hypotension and respiratory depression. Endotracheal intubation is often necessary.

Refractory Status Epilepticus (RSE) Consider one of the following pharmacologic agents. Intubation will be required for all except valproate. Continuous EEG monitoring should be instituted while using these agents.

Administer midazolam in a loading dose of 0.2 mg/kg followed by an infusion of 0.05–2.0 mg/kg per hour. Hypotension is rare compared to propofol.

Propofol, at a dose of 3–5 mg/kg load followed by an infusion of 1–15 mg/kg per hour.

Successful termination of RSE has been reported with valproic acid administration. Intubation may be avoided when using this agent.

Pentobarbital given at a loading dose of 5–10 mg/kg followed by and infusion of 0.5–10 mg/kg per hour titrated to burst suppression on EEG. Hypotension and myocardial depression are prominent side effects.

Patients in status epilepticus or those given anticonvulsant medications that are strong respiratory depressants may require endotracheal intubation to protect the airway and maintain adequate ventilation.

CT Scan When feasible, a CT scan of the head should be performed on all patients with new onset seizures.

Antiepileptic Therapy

Emergency physicians need not initiate antiepileptic medication (medications prescribed for seizure prevention) in the ED for patients who have had a first provoked seizure or for patients who have had a first unprovoked seizure without evidence of brain disease or injury.

Hospital admission Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.