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Treatment of Patients with Epilepsy Emergencies



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Am Fam Physician. 1999 May 15;59(10):2872.

Patients with a seizure disorder are commonly seen in the primary care setting. Some of these patients present with status epilepticus. The cardinal feature of status epilepticus is continuous or repeating seizures that occur so rapidly that the patient does not recover consciousness between them. Status epilepticus is a danger to the patient and a treatment challenge to the physician. Willmore reviews the treatment of epilepsy emergencies, with special emphasis on the management of patients with status epilepticus.

The author presents a timetable for the appropriate treatment of status epilepticus (see accompanying table). After the diagnosis has been confirmed, treatment is initiated with either acute emergency management or rational drug administration. Emergency care is designed to prevent injury, whereas drug treatment is guided by its ability to limit morbidity associated with systemic changes or seizure-induced neuronal damage.

Timetable for the Treatment of Status Epilepticus

Minutes Action

0 to 5

Confirm diagnosis by observing seizure activity or one additional seizure

Administer oxygen by nasal cannula or mask; control head position and airway; evaluate need for intubation if ventilatory assistance is needed

Obtain and record vital signs; continue to observe; treat any abnormalities; establish ECG recording

Obtain IV access, keep open with 0.9 percent saline; use glucometer or draw venous blood for glucose, serum chemistries, hematology, toxicology and AED levels

Evaluate oxygenation with oximetry or arterial blood gas determinations

6 to 9

If patient is hypoglycemic or if blood sugar measurement is not available, give glucose: adults, 100 mg IV thiamine followed by 50 mL of 50 percent glucose by IV push; children, 2 mL per kg of 25 percent glucose

10 to 20

In adults, administer IV either 0.1 mg per kg of lorazepam at 2 mg per minute up to 4 mg total dose or 0.2 mg per kg of diazepam at 5 mg per minute up to 20 mg maximum

Diazepam can be repeated if seizures continue after 5 minutes

Diazepam must be followed by loading with phenytoin

20+

Load with 20 mg per kg phenytoin no faster than 50 mg per minute in adults and 1 mg per kg per minute in children; monitor ECG and blood pressure during infusion; IV fluids must be 0.9 percent saline

Fosphenytoin may be given at 150 phenytoin-equivalents per minute as a safe substitute for phenytoin

>60

If status continues after 20 mg per kg of phenytoin, give additional phenytoin or fosphenytoin at 5 mg per kg until a maximum of 30 mg per kg

If status persists, give 20 mg per kg of IV phenobarbital at 60 mg per minute

Expect apnea, particularly if the patient has received benzodiazepines

Assist ventilation; intubation will be required

If status persists, use anesthesia with pentobarbital, midazolam or propofol; intubation, ventilation and vasopressors will be required


(ECG = electrocardiogram; IV = intravenous; AED = anti-epileptic drug)

Reprinted with permission from Willmore LJ. Epilepsy emergencies. The first seizure and status epilepticus. Neurology 1998;51(suppl 4):S34-8.

Timetable for the Treatment of Status Epilepticus

View Table

Timetable for the Treatment of Status Epilepticus

Minutes Action

0 to 5

Confirm diagnosis by observing seizure activity or one additional seizure

Administer oxygen by nasal cannula or mask; control head position and airway; evaluate need for intubation if ventilatory assistance is needed

Obtain and record vital signs; continue to observe; treat any abnormalities; establish ECG recording

Obtain IV access, keep open with 0.9 percent saline; use glucometer or draw venous blood for glucose, serum chemistries, hematology, toxicology and AED levels

Evaluate oxygenation with oximetry or arterial blood gas determinations

6 to 9

If patient is hypoglycemic or if blood sugar measurement is not available, give glucose: adults, 100 mg IV thiamine followed by 50 mL of 50 percent glucose by IV push; children, 2 mL per kg of 25 percent glucose

10 to 20

In adults, administer IV either 0.1 mg per kg of lorazepam at 2 mg per minute up to 4 mg total dose or 0.2 mg per kg of diazepam at 5 mg per minute up to 20 mg maximum

Diazepam can be repeated if seizures continue after 5 minutes

Diazepam must be followed by loading with phenytoin

20+

Load with 20 mg per kg phenytoin no faster than 50 mg per minute in adults and 1 mg per kg per minute in children; monitor ECG and blood pressure during infusion; IV fluids must be 0.9 percent saline

Fosphenytoin may be given at 150 phenytoin-equivalents per minute as a safe substitute for phenytoin

>60

If status continues after 20 mg per kg of phenytoin, give additional phenytoin or fosphenytoin at 5 mg per kg until a maximum of 30 mg per kg

If status persists, give 20 mg per kg of IV phenobarbital at 60 mg per minute

Expect apnea, particularly if the patient has received benzodiazepines

Assist ventilation; intubation will be required

If status persists, use anesthesia with pentobarbital, midazolam or propofol; intubation, ventilation and vasopressors will be required


(ECG = electrocardiogram; IV = intravenous; AED = anti-epileptic drug)

Reprinted with permission from Willmore LJ. Epilepsy emergencies. The first seizure and status epilepticus. Neurology 1998;51(suppl 4):S34-8.

The author concludes that the cause of status epilepticus must be determined in any patient who presents with this disorder. Investigations should include brain imaging studies to rule out any mass lesions or evidence of ventricular obstruction. If the patient is febrile and there is no evidence of mass lesions or ventricular obstruction, a lumbar puncture should be performed.

Willmore LJ. Epilepsy emergencies. The first seizure and status epilepticus. Neurology. November 1998;51(suppl 4):S34–8.


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