seizures dr. samir shahani
DESCRIPTION
Dr. Samir Shahani's Senior Grand Rounds Presentation on evidenced based approach to seizures.TRANSCRIPT
![Page 1: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/1.jpg)
SHAKEand BAKE
SAMIR SHAHANI PGY-3
![Page 2: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/2.jpg)
![Page 3: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/3.jpg)
Time is Brain
![Page 4: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/4.jpg)
Why should you Care?
- Prevalence: 1 out of 100 people- 1-2% of all ED visits- 3 million people in US
- 200,000 new cases each year
- Overall Mortality of Status is 20%
![Page 5: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/5.jpg)
Differential
• Syncope• Metabolic Conditions• Migraine• Vascular Conditions• Sleep Disorders• Paroxysmal Movement Disorders• Psychological Disorders• Infection• Trauma• Malignancy
![Page 6: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/6.jpg)
Seizure Classification
• Provoked Seizure– Electrolyte Abnormalities–Withdrawal vs Toxic Ingestion– Infection– CNS Mass– Pregnancy– Trauma
• Unprovoked Seizures
![Page 7: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/7.jpg)
The Basics
• Generalized• Focal (Partial)• Focal with Secondary Generalization• Status Epilepticus
![Page 8: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/8.jpg)
Status Epilepticus Definition
• Epidemiologic• ≥ 30 minutes
• New Definition• ≥ 5 minutes• 2 or more seizures without recovery of
consciousness
• Pathological• Failure of inhibitory pathways (GABA)
![Page 9: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/9.jpg)
The Assessment
![Page 10: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/10.jpg)
History• First Time Seizure vs Recurrence?• Describe Event–Movement– Eye Deviation– Duration
• Medications• Social History• Review of Systems
![Page 11: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/11.jpg)
Physical
• Vitals• General• Eyes• Neck• Neurological
![Page 12: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/12.jpg)
Labs• Glucose• Electrolytes• Pregnancy Test• Toxicology Studies• CSF Studies• Lactate• Prolactin• Antiepilectic Drug (AED) Levels• Blood Gas
![Page 13: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/13.jpg)
Imaging and Diagnostic Studies
• CT Head w/o Contrast• MRI w/o Contrast• EEG
![Page 14: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/14.jpg)
Management
![Page 15: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/15.jpg)
New Onset Seizures
CT Head Without Contrast– Easy to obtain– First Time Seizures in setting of Etoh or
Etoh Withdrawal: 6.2% had significant finding
Lumbar Puncture– Fever, Immunocompromised, AMS, severe
HA
![Page 16: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/16.jpg)
New Onset Seizures
Should I Start AED?– Recurrence Rate < 30-50%– Consider Starting If:• Structural lesion on CT• Focal Deficit• Positive EEG
![Page 17: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/17.jpg)
Abortive Therapies
![Page 18: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/18.jpg)
Benzodiazpines
• Diazepam– Quickest Onset– Dose: 10 mg PR, IM
• Midazolam– Fast Onset– Dose: • 2-4 mg IV, IM• 5 mg per nostril IN
![Page 19: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/19.jpg)
Benzodiazpines
• Lorazepam– Longer Duration of Action– Can be used alone– Dose: 2-4 mg IV, IM
![Page 20: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/20.jpg)
Phenytoin vs Fosphenytoin
• No studies have compared efficacy• Phenytoin is generally cheaper• Fosphenytoin is well tolerated• Fosphenytoin reaches the Brain
Faster
![Page 21: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/21.jpg)
Fosphenytoin
• Does not Contain Propylene Glycol• Can be Given Faster than Phenytoin– Phenytoin 50 mg/min– Fosphenytoin 150 PE/min
• Dose: 20 mg/kg ± 10 mg/kg
![Page 22: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/22.jpg)
Phenobarbital
• 20 mg/kg over 20 minutes• Risk of Apnea and Hypotension• Get Ready To Intubate
![Page 23: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/23.jpg)
Other Agents
• Valproic Acid– Avoid in Hepatic Disease– Teratogenic– Dose: 20 mg/kg
• Levitracetam– Extremely Safe– Dose: 20 mg/kg
![Page 24: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/24.jpg)
“The Longer A seizure Persists, the more refractory to treatment it will become”
Wheless, 1996
![Page 25: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/25.jpg)
Time To Treatment = Response
Duration (Min) All Seizures Stop
7.3 ± 2.57 6/6
16.2 ± 5.06 3/6
38.7 ± 15.5 1/6
127.0 ± 10.3 1/6
Wheless, 1996
*Data Using Diazepam
![Page 26: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/26.jpg)
![Page 27: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/27.jpg)
Seizures Simplified
![Page 28: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/28.jpg)
Seizures Simplified
Stabilize the Patient
![Page 29: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/29.jpg)
Seizures Simplified
Finger Stick Blood Glucose
![Page 30: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/30.jpg)
Seizures Simplified
Time Seizure Monitor Vital Signs
![Page 31: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/31.jpg)
Seizures Simplified
Attempt IV AccessCollect Blood
![Page 32: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/32.jpg)
Seizures Simplified
If Glucose < 60 mg/d
Adults: 100 mg Thiamine, 1 amp D50Children: >2 yrs 2ml/kg D25W
< 2 yrs 4ml/kg D12.5W
![Page 33: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/33.jpg)
Seizures Simplified
IV Access?
Yes. IV Lorazepam x 2 q 3 minand then Fosphenytoin
No. PR DZP, IN MDZ, IM MDZ, IO
![Page 34: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/34.jpg)
Seizures Simplified
Seizure Continues?
Yes. Levetiracetam, Valproic Acid, Phenobarbital, Versed,
PropofolNo. Continue Medical CareMaybe. Bedside EEG
![Page 35: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/35.jpg)
Refractory Status Epilepticus
Claassen J et al, Epilepsia, 2002; 43: 146-153
Midazolam (N=54)
Propofol (N = 33)
Pentobarbital (N=106)
Acute Treatment Failure
20% (11) 27% (9) 8% (8)
Seizure Recurrence
51% (23) 15% (2) 12 % (11)
Ultimate Treatment Failure
21% (10) 20% (4) 3% (3)
Hypotension- Vasopressors Needed
30% (14) 42% (10) 77% (79)
![Page 36: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/36.jpg)
Evidence Based Medicine
![Page 37: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/37.jpg)
2004 ACEP Clinical Policy
• What Lab Tests?– Level B: Glucose, Sodium, Calcium,
Consider LP, Pregnancy Test
• Should you get CT on first time seizure?– Level B: Yes
![Page 38: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/38.jpg)
2014 ACEP Clinical Policy
• First Time Seizure, Start AEDs?– Level C: No.
• Admit First Time Seizures?– Level C: No.
![Page 39: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/39.jpg)
2014 ACEP Clinical Policy
• Known Seizure Disorder, Does Route of Loading affect recurrence?– Level C: No.
• Status Epilepticus, Benzo’s Did not work?– Level A: Try something else– Level B: Fosphenytoin, Phenytoin, Valproate– Level C: Levetiracetam, Propofol, Barbituates
![Page 40: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/40.jpg)
Take Home
• Time is Morbidity and Success• Check a Glucose• Think Secondary Causes• Simplify Seizures: Have a Plan
![Page 41: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/41.jpg)
Status Algorithm Seizure > 5 min
ABC’sNo IV
AccessIM/IN Midazolam, IM/PR Diazepam
or IO
Yes IV Access
Lorazepam 2-4mg IV q 3
min
Fosphpenytoin20-30 mg/kg IV
Sz Continues?
Phenobarbital 20-30 mg/kgIV or
Valproic Acid 20 mg/kg
InfusionPropofolVersed
Pentobarbital
Sz Continues?
![Page 42: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/42.jpg)
Thanks and ?’s
Special Thanks Dr. Williams
![Page 43: Seizures Dr. Samir Shahani](https://reader031.vdocuments.site/reader031/viewer/2022012916/556e5cbad8b42a6a248b472a/html5/thumbnails/43.jpg)
Resources• Dodson WE et al, JAMA, 1993; 270: 854-859.• Lowenstein DH et al, Epilepsia; 1999; 40: 120-122.• Corey LA et al, Neurology, 1998; 50: 558-560.• Hauser WA, Hesdorffer DC. Epilepsy: frequency, causes, and
consequences. New York: Demos Publications; 1990.• EarnestMP,Etal.Neurology 1988; 38: 1561-5• Prasad K, Al-Roomi K, Krishnan PR, et al. Anticonvulsant therapy for
status epilepticus.Cochrane Database Syst. Rev. 2005, Issue 4. Art No.:CD003723. DOI: 10.1002/14651858.CD003723.pub2.
• American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. May 2004;43(5):605-25
• Claassen J, Hirsch LJ, Emerson RG, Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. Feb 2002;43(2):146-53.