management of seizures in ed
DESCRIPTION
ACEP Clinical Policy Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures Ann Emerg Med. 2014;63:437-447.TRANSCRIPT
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ANN EMERG MED. 2014;63:437-447.
ACEP Clinical PolicyCritical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Seizures
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The American College of Emergency Physicians’ (ACEP) 2004 clinical policy on seizures addressed 2 critical questions on laboratory testing and neuroimaging:
1. What laboratory tests are indicated in the otherwise healthy adult patient with a newonset seizure who has returned to a baseline normal neurologic status?
2. Which new-onset seizure patients who have returned to a normal baseline require a head CT in the ED?
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This clinical policy from the ACEP is the revision of a 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the ED to help clinicians answer the following critical questions:
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In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?1
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In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events? 2
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In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures? 3
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In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? 4
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Classification of Seizures
Provoked seizure– acute symptomatic seizure
Unprovoked seizure– including remote symptomatic
seizure
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Provoked seizureDefinition
Provoked seizure equivalent to acute symptomatic seizure; seizure occurs at time of or within 7 days of an acute neurologic, systemic, metabolic, or toxic insult
Examples
Seizures from hyponatremia or other electrolyte abnormalities, withdrawal, toxic ingestions, encephalitis, CNS mass lesions, and many others
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Unprovoked seizureDefinition
Seizure occurs without acute precipitating factors; unprovoked seizures include but are not limited to remote symptomatic seizures if seizure is thought to result from CNS or systemic insult that occurred more than 7 days in the past
Examples
Idiopathic seizures; epilepsy (if recurrent); seizure attributed to history of stroke, traumatic brain injury, or other past events
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Classes of Evidence to Recommendation Levels
Level A recommendationsGenerally accepted principles for patient care that reflect a high degree of clinical certainty
Level B recommendationsRecommendations for patient care that may identify a particular strategy or range of strategiesthat reflect moderate clinical certainty
Level C recommendationsRecommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus
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Scope of ApplicationThis guideline is intended for physicians working in EDs
Inclusion CriteriaThis guideline is intended for adult patients aged 18 years and older presenting to the ED with generalized convulsive seizures
Exclusion CriteriaThis guideline is not intended for pediatric patients, patients with complex partial seizures, patients with acute head trauma or multisystem trauma, patients with brain mass or brain tumor, immunocompromised patients, or patients with eclampsia
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Critical Questions
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In patients with a first generalized convulsive seizure who have returned to their baseline clinical status, should antiepileptic therapy be initiated in the ED to prevent additional seizures?1
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Level C recommendations
1. Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first provoked seizure. Precipitating medical conditions should be identified and treated.
* Antiepileptic medication in this document refers to medications prescribed for seizure prevention.
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Level C recommendations
2. Emergency physicians need not initiate antiepileptic medication* in the ED for patients who have had a first unprovoked seizure without evidence of brain disease or injury.
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Level C recommendations
3. Emergency physicians may initiate antiepileptic medication* in the ED, or defer in coordination with other providers, for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury.
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In patients with a first unprovoked seizure who have returned to their baseline clinical status in the ED, should the patient be admitted to the hospital to prevent adverse events? 2
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Level C recommendations
Emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED.
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Dunn et al proposed a disposition algorithm for patients with uncomplicated first generalized seizure that uses glucose, CT scan (if indicated and done), ECG, and blood tests for renal function, electrolyte level, calcium level, and blood count.
They proposed that the patient with normal results may be discharged, provided the following criteria are satisfied: full recovery without abnormal neurologic signs and/or symptoms, normal vital signs, received advice not to drive, availability of a responsible adult to watch him or her, follow-up arranged, and follow-up likely.
Emerg Med J 2005;22:237–242
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In patients with a known seizure disorder in which resuming their antiepileptic medication in the ED is deemed appropriate, does the route of administration impact recurrence of seizures? 3
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Level C recommendations
When resuming antiepileptic medication in the ED is deemed appropriate, the emergency physician may administer IV or oral medication at their discretion.
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Loading dose and route of administration strategies for antiepileptic medications in the ED
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Carbamazepine (Tegretol, Equetro)
Loading Dose
8 mg/kg oral suspension, single oral load; IV not available
Adverse Effects
Common drowsiness, nausea, dizziness
Notes
Oral tablet has slow/erratic absorption
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Gabapentin (Neurontin, Gralise)
Loading Dose
900 mg/day oral (300 mg tid) for 3 days; IV not available
Adverse Effects
Somnolence, dizziness, ataxia, and fatigue
Notes
Adjunct for partial seizures
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Lamotrigine (Lamictal)
Loading Dose
6.5 mg/kg single oral load if on lamotrigine for >6 mo without a history of rash or intolerance in the past and only off lamotrigine for <5 days; IV not available
Adverse Effects
Mild, transient nausea
Notes
Frequent and serious rashes; do not load if history of rash or patient not previously on lamotrigine
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Levetiracetam (Keppra)
Loading Dose
1,500 mg oral load; rapid IV loading safe and well tolerated in doses up to 60 mg/kg
Adverse Effects
Fatigue, dizziness, rarely pain at infusion site
Notes
Frequent and serious rashes; do not load if history of rash or patient not previously on lamotrigine
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Phenytoin (Dilantin, Phenytek)
Loading Dose
20 mg/kg divided in maximum doses of 400 mg every 2 h orally, or 18 mg/kg IV at maximum rate of 50 mg/min
Adverse Effects
IV is faster to load but more serious adverse effects than oral, including hypotension, bradyarrhythmias, cardiac arrest, and extravasation injuries
Notes
Oral is cheaper but takes >5 h to reach therapeutic levels; IV requires filter, infusion pump
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Fosphenytoin (Cerebyx)
Loading Dose
18 PE/kg IV at maximum rate of 150 PE/min; IM administration possible
Adverse Effects
Fewer adverse events in head-to-head analysis between IV fosphenytoin and IV phenytoin load
Notes
Generic now available with significant cost reduction
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Valproate (Depacon)
Loading Dose
Up to 30 mg/kg IV at max rate of 10 mg/kg/min IV
Adverse Effects
Transient local irritation at injection site
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In ED patients with generalized convulsive status epilepticus who continue to have seizures despite receiving optimal dosing of a benzodiazepine, which agent or agents should be administered next to terminate seizures? 4
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Level A recommendations
Emergency physicians should administer an additional antiepileptic medication in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
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Level B recommendations
Emergency physicians may administer intravenous phenytoin, fosphenytoin, or valproate in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
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Level C recommendations
Emergency physicians may administer intravenous levetiracetam, propofol, or barbiturates in ED patients with refractory status epilepticus who have failed treatment with benzodiazepines.
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Patients who continue to have generalized convulsive status epilepticus failed first-line treatment with optimal dosing of benzodiazepines should be given an additional anticonvulsant agent.
Simultaneously, one should search for treatable causes of status epilepticus, including hypoglycemia, hyponatremia, hypoxia, drug toxicity, withdrawal syndromes, systemic or CNS infection, ischemic stroke, intracerebral hemorrhage.
If a provoking cause is discovered for status epilepticus, condition-specific treatment should be given.
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The Neurocritical Care Society’s Status Epilepticus Guideline Writing Committee recommended urgent control of seizures with any of the following: valproate, levetiracetam, or phenobarbital, in addition to phenytoin/fosphenytoin. Valproate was recommended for both emergent treatment of seizures and refractory status epilepticus based on high-level evidence.
Neurocrit Care. 2012;17:3-23.
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The European Federation of Neurological Societies’ evidence-based guideline for status epilepticus in adults recommended anesthetic doses of midazolam, propofol, or barbiturates for status epilepticus refractory to benzodiazepines and phenytoin.
Eur J Neurol. 2010;17:346-355.
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IV medication options for generalized convulsive status epilepticus
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Phenytoin (Dilantin, Phenytek)
Dose
18-20 mg/kg administered no faster than 50 mg/kg; some recommend to increase to total 30 mg/kg if seizures continue
Adverse Effects
Soft tissue injury with extravasation, hypotension, cardiac dysrhythmias, purple glove syndrome
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Fosphenytoin (Cerebyx)
Dose
18-20 PE/kg administered no faster than 150 PE/min
Adverse Effects
Hypotension, cardiac dysrhythmias
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Valproate (Depacon)
Dose
20 to 30 mg/kg at rate of 40 mg/min (faster administration rates also reported)
Adverse Effects
Dizziness, thrombocytopenia, liver toxicity, hyperammonemia
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Levetiracetam (Keppra)
Dose
30–50 mg/kg IV load at 100 mg/min
Adverse Effects
Nausea, rash
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Propofol (Diprivan)
Dose
2 mg/kg; may repeat in 3-5 min; maintenance infusion of 5 mg/kg/h
Adverse Effects
Injection site pain, heart failure, respiratory support required
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Phenobarbital (Luminal)
Dose
10-20 mg/kg; may repeat 5-10 mg/kg at 10 min
Adverse Effects
Respiratory depression, hypotension
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Valproate works as well in status epilepticus after benzodiazepine administration as a second-line agent as phenytoin and fosphenytoin.
Levetiracetam is safe, with low incidence of hypotension and respiratory depression when given as an IV load.
Propofol can be useful in intubated patients who continue to seize, provided they do not exhibit hypotension.
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Questions ?