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1.) SE affects whom the most?
2.) T/F? They typically have a Hx of epilepsy
- 1.) Very young (< 1yr) and elderly (>60 yrs)
- 2.) False
Common precipitating causes of SE:
- 1.) AED withdrawal*
- 2.) Infection
- 3.) Metabolic disorder/ electrolyte disorder
- 4.) Cerebrovascular disease (esp in elderly)*
- 5.) Pre-existing neurological disease progression
- 6.) Neurologic lesions (ex. brain tumor)
- 7.) Neurologic insult (trauma)
- 8.) Alterations in AED serum conc.*
What labs should be acquired in cases of SE? (Though labs should not delay therapy)
- 1. Glucose (low BG could be the cause)
- 2. Electrolytes
- 3. AED levels
- 4. SCr
- 5. Albumin
- 6. CBC w/ differential
- 7. LFTs
- 8. Urine screen for drugs/alcohol
- 9. ABG
- 10. Blood cultures to rule out infection
What diagnostic tool is most important for cases of SE?
- EEG on presentation and after GCSE is controlled. Abnormal electrical activity may be present even in the absence of outward symptoms.
What are the three treatment goals of therapy for SE?
- 1. Immediate termination of all clinical and electrical seizure activity
- 2. Avoid recurrent seizure activity
- 3. Minimize drug toxicities
Initial hospital treatment course (7):
- 1.) Vital signs, protect airway, maintain ventilation, administer oxygen
- 2.) Place IV catheters and start fluids (2 sites since phenytoin is not very compatible with others)
- 3.) Draw labs
- 4.) Admin. thiamine 100 mg IV (to prevent wernike encephalopathy in case alcoholic seizure)
- 5.) Amin. D50W (to restore glucose in case a hypoglycemic seizure)
- 6.) If pH < 7.2, give Na bicarb to treat metab acidosis
- 7.) Administer lorazepam 2-4 mg IV bolus
1.) What medication is the initial DOC in all cases of SE without contras?
2.) Dose and route
3.) What medication is in same DOC class but should only be used in cases of refractory SE or if no IV access is available?
4.) Major side fx of this class of drugs
- 1.) Benzos --> specifically lorazepam.
- 2.) 4 mg (2 mg if elderly) IV bolus, may repeat in 5 mins if seizure persists
- 3.) Midazolam (Versed)
- 4.) Sedation, respiratory depression, hypotension following large doses
- *Pts on chronic Benzos will require higher doses
- *Lorazepam provides seizure coverage for 6-24 hours
1.) What medication(s) is/are 2nd line treatments for SE and are often administered at the same time as a benzodiazepine?
2.) Dose, route
- 1.) Hydantoins (phenytoin or fosphenytoin)
- 2.) LD 15-20 mg/kg IV, MD 5mg/kg/day IV initiated 12-24 hours after LD
1.) A disadvantage of phenytoin, the maximum infusion rate is _____ mg/min in adults and _____ mg/min in the elderly.
2.) Target serum conc. of phenytoin is _____-_____ mcg/mL
3.) What lab parameter must be considered when dosing phenytoin?
4.) Phenytoin contains propylene glycol, which may cause ______ and ______, and should therefore be avoided in _______ and those with pre-existing ______.
5.) Phenytoin infusions may cause what reactions at injection site?
- 1.) 50 mg/min, 25 mg/min
- 2.) 10-20 mcg/mL
- 3.) Albumin (normal 3.5-5.5 g/dL)
- 4.) hypotension and arrhythmias, elderly patients, cardiac disease (monitor ECG and slow infusion if QT interval widens or these sxs occur!)
- 5.) Phlebitis/tissue necrosis
What toxicities may occur if serum concentrations of phenytoin exceed 10-20 mcg/mL?
- - ataxia
- - nystagmus
- - N&V
- - stupor
- - coma
- - death
What is the dose and route of FOS?
- LD 15-20 PE/kg IV
- MD 5 mg PE/kg IV
*1.5 mg FOS = 1 mg phenytoin
Advantages of FOS over phenytoin (6):
- 1.) Faster admin (150 mg PE/min)
- 2.) Lower frequency of ECG changes and hypotension
- 3.) No propylene glycol
- 4.) Greater IV compatibilities
- 5.) IM admin. if no IV access available
Adverse effect unique to FOS:
- Parasthesia and pruritis of the face and groin.
- Typically subsides in 5 - 10 mins.
Phenobarbital is considered 3rd line therapy for SE, unless pt is allergic to _______ or _______, or if ________ abnormalities are present.
- 1.) benzos
- 2.) hydantoins
- 3.) cardiac conduction
Dose and route for phenobarbital:
LD 10-20 mg/kg IV at 100 mg/min (repeat if necessary)
MD 1-4 mg/kg IV
Adverse effects of phenobarbital:
- 1.) CNS depression (sedation)
- 2.) Respiratory depression
- 3.) hypotension
Treatments for refractory SE (4)?
- 1.) Propofol
- 2.) Benzodiazepine continuous infusion
- 3.) Valproate IV
4.) If above are not successful, pentobarbital infusion (medically induced coma)