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ER treatment of Epilepsy


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Emergency Room (ER) treatment of Epilepsy

Published in: Health & Medicine
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ER treatment of Epilepsy

  1. 1. Treatment of Epilepsy in ER Submitted to AskTheNeurologist.Com in 2007 Author Anon.
  2. 2. The first seizure <ul><li>Is it really first event? </li></ul><ul><li>If established that it is, in fact first, unprovoked event decision to treat depends on </li></ul><ul><li>- risk factors for recurrence </li></ul><ul><li>- risks of drug treatment </li></ul><ul><li>- patient preference </li></ul>
  3. 3. Seizure recurrence <ul><li>Over 50% of patients who will have recurrence following first seizure will do so within 6 months </li></ul><ul><li>Recurrence rate varies from 36 – 77% </li></ul><ul><li>If careful history taken to ensure seizure is definitely “ first ever” then recurrence rate drops to 35% </li></ul><ul><li>Recurrence rate following second seizure is 80-90% </li></ul>
  4. 4. Risk factors for seizure recurrence <ul><li>History of prior neurological injury or lesion </li></ul><ul><li>History of epilepsy in a sibling </li></ul><ul><li>Transient neurological deficit ( Todd’s ) </li></ul><ul><li>EEG with generalised epileptiform discharges </li></ul>
  5. 5. Treatment of status epilepticus <ul><li>Acute emergency management </li></ul><ul><li>- Prevents injury </li></ul><ul><li>Rational drug administration </li></ul><ul><ul><li>- Limits morbidity due to systemic changes or seizure-induced neuronal damage </li></ul></ul>
  6. 6. Definitions <ul><li>ILE: “ seizure that persists for a sufficient length of time or is repeated frequently enough that recovery between attacks does not occur” </li></ul><ul><li>Most literature specifies time period of 20-30 minutes as estimate of time necessary to cause injury to CNS </li></ul>
  7. 7. Operational definition <ul><li>“ Continuous seizures lasting at least 5 minutes or 2 or more discrete seizures between which there is incomplete recovery of consciousness” </li></ul>
  8. 8. Predictors of outcome <ul><li>Age </li></ul><ul><li>Cause - Metabolic </li></ul><ul><ul><ul><ul><li>- Infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- CVA </li></ul></ul></ul></ul><ul><ul><ul><ul><li>- Trauma </li></ul></ul></ul></ul><ul><li>Known epileptic patients have best prognosis </li></ul>
  9. 9. Outcomes <ul><li>Overall mortality is 20% </li></ul><ul><li>Patients whose first ever seizure is status epilepticus have substantial risk of future episodes and the developmennt of chronic epilepsy </li></ul><ul><li>Predominant factor affecting outcome is cause </li></ul><ul><li>Myoclonic status epilepticus after hypoxia carries especially grave prognosis </li></ul><ul><li>Duration of status epilepticus is correlated with neurological morbidity and lack of responsiveness to drug treatment </li></ul>
  10. 10. Assessment and supportive measures <ul><li>ABC - protect airway </li></ul><ul><ul><ul><ul><ul><li>100 % O2 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>BP control </li></ul></ul></ul></ul></ul><ul><li>Monitoring - ECG </li></ul><ul><li>- BP </li></ul><ul><li>- ABG’s </li></ul><ul><li>- Biochemistry </li></ul><ul><li>- Body temperature </li></ul>
  11. 11. Glucose <ul><li>Hypoglycemia should be excluded </li></ul><ul><li>Usually treat empirically with 50ml of 50% glucose </li></ul><ul><li>Should always precede glucose administration with 100mg thiamine IV </li></ul>
  12. 12. Blood pressure <ul><li>Hypertension usually occurs early in course </li></ul><ul><li>Subsequently BP labile and often drops </li></ul><ul><li>Fluids and vasopressors may be required </li></ul><ul><li>Aim for high/normal range </li></ul>
  13. 13. Body temperature <ul><li>May often be result of seizures themselves rather than co-existing infection </li></ul><ul><li>Should be treated with passive cooling </li></ul>
  14. 14. Systemic treatment <ul><li>Avoid over-hydration ( cerebral oedema ) </li></ul><ul><li>Blood tests ( including Ca, Mg) </li></ul><ul><li>Monitor oxygenation </li></ul><ul><li>Monitor rectal temperature </li></ul>
  15. 15. 1 st line drug treatments <ul><li>Benzodiazepines </li></ul><ul><li>- Diazepam vs Lorazepam </li></ul><ul><li>Phenytoin vs Fosphenytoin </li></ul><ul><li>Phenobarbital </li></ul>
  16. 16. Benzodiazepines Can be used alone Necessitates use of a second long-acting drug Longer duration of action Rapid redistribution into body fat Less rapid penetration into brain More rapid penetration into brain Less lipid soluble More lipid soluble Lorazepam Diazepam
  17. 17. Lorazepam <ul><li>“ Despite their equivalence as initial therapies, lorazepam has a longer duration of antiseizure effect ( 12-24 hours ) than diazepam ( 15-30 minutes)…..lorazepam preferable to diazepam for the treatment of status epilepticus” </li></ul>
  18. 18. Fosphenytoin <ul><li>Water-soluble prodrug form of phenytoin </li></ul><ul><li>Does not contain propylene glycol </li></ul><ul><li>( which is main limiting factor for rate of treatment as contributes to cardiovascular side effects) </li></ul><ul><li>Less irritant </li></ul><ul><li>Can be given at a maximum rate of 150 phenytoin equivalents / minute </li></ul><ul><li>Phenytoin itself may only be administered at a maximum rate of 50mg/min </li></ul>
  19. 19. Maximal brain concentrations of phenytoin <ul><li>Attainable in 20-25 minutes when phenytoin infused at maximal rate </li></ul><ul><li>Attainable within 10 minutes when Fosphenytoin infused at maximal rates </li></ul>
  20. 20. Phenobarbital <ul><li>“ Highly effective” </li></ul><ul><li>Recommend 20mg/kg at rate of 50 – 75 mg/min </li></ul><ul><li>Risk of apnea….especially if patient has received BZD’s </li></ul>
  21. 21. IV Valproic acid <ul><li>Effective in some forms of status epilepticus </li></ul><ul><li>At time of publication insufficient experience available </li></ul>
  22. 22. Refractory status epilepticus <ul><li>Failure to control seizures with BZD’s, phenytoin and phenobarbital </li></ul><ul><li>Requires administration of iv anaesthetic agent - Barbiturates </li></ul><ul><li>- Midazolam </li></ul><ul><li>- Propofol </li></ul><ul><li>EEG performed at 12hrs and thereafter every 24 hours </li></ul>
  23. 23. Recommend saline and dopamine infusion Myocardial depression Vasodilatation Decreased venous return Decreased cardiac perfusion Associated with profound systemic side effects Assessment clinical and on basis of EEG Potent Doses adjusted on basis of EEG responses Tachyphylaxis necessitates dose variation Pentobarbital Propofol Midazolam
  24. 24. Recommendations regarding Barbiturates <ul><li>Severe hypotension requiring pressor therapy limits safety of barbiturates </li></ul><ul><li>Preferable to reserve anaesthesia with barbiturates for patients in whom midazolam or propofol fails </li></ul>
  25. 25. Submitted to AskTheNeurologist.Com in 2007 Author Anon.