Emergency Management of Emergency Management of SeizuresSeizures
Deb Funk, M.D., NREMT-P
Medical Director;
Albany MedFLIGHT
Saratoga EMS
GoalsGoals
Review definitions, classifications and pathophysiology
Discuss several patient scenarios– Assessment– Management
Discuss current pharmacologic techniques for management of ongoing seizures
DefinitionsDefinitions
Seizure: episodic abnormal neurologic functioning caused by abnormally excessive activation of neurons
Epilepsy: a clinical condition characterized by recurrent seizures
status epilepticus: >30min seizure or >2 seizures w/o recovery
EpidemiologyEpidemiology
6-10% of US population will have at least 1 afebrile seizure during their lifetime
1-2% have recurrent seizures100,000 new cases in US annually
– Adult first time seizures represent 1% of all ED visits
incidence highest <20 and >60yrsMale > female
ClassificationClassification primary/secondary
– Primary do not have obvious source– Secondary occur as a result of many types of
injuries/illnesses
generalized/focal– generalized involves abnl neuron activity in both cerebral
hemispheres tonic/clonic, absence, myoclonic
– focal involve 1 hemisphere simple partial, complex partial, secondarily generalized
Generalized: Tonic-Clonic Generalized: Tonic-Clonic SeizureSeizure
most commonvague prodromal symptomstonic phase
– trunk flexion-->extension, eyes deviate up, mydriasis, vocalization
clonic phase– tonic contractions alternate with muscle atonia
Generalized: Tonic-Clonic Generalized: Tonic-Clonic cont’dcont’d
loss of consciousness and autonomic alterations during both phases
any focality noted during or after seizure may point to the origin
hypocarbia (resp alkalosis/lactic acidosis), transient hyperglycemia, CSF pleocytosis, elevated serum prolactin
post ictal phase– coma-->confusional state-->lethargy, myalgia,
headache
Pathophysiology of SeizuresPathophysiology of Seizures
in general not well understood neuronal recruitment is a common theory and has
been demonstrated in some studies– propagation of abnormal electrical impulse to adjacent
neurons along variable paths– the pathway involved usually determines the type of
seizure seen generalized sz: focus deep and midline, involving the RAS focal sz: more limited focus of activity/does not cross midline
Pathophysiology cont’dPathophysiology cont’d
typically self limited– bursts of electrical discharges from the focus
terminate reflex inhibition/neuronal exhaustion/alteration of
neurotransmitter balance.
Case 1Case 1
2 yr old previously healthy boy given Tylenol for tactile temp by Mom. Twenty min later had “shaking episode.”
What more do you need to know?What do you look for on exam?What is your assessment and plan?
Febrile Seizure: DefinitionsFebrile Seizure: Definitions
generalized seizure occurring during a sudden rise in temp in absence of intracranial infection or other defined etiology
Simple: single event lasting less than 15 min (90%)
Complex: exceed 15 min, occur more than once in 24hr period, or show focal motor manifestations (higher rate of epilepsy)
Febrile Seizure: StatisticsFebrile Seizure: Statistics
2-5% of childrenmost common pediatric seizure30% will have a single recurrence (1/2 of
these will have multiple)age of onset 6mos-5yrs (peak 18-24 mos)family history conveys 2-3 times the
general population risk2-9% develop afebrile seizures
Febrile Seizures: AssessmentFebrile Seizures: Assessment
History– PMH/AMPLE (immunization hx)– Recent illness– Details of event
Physical Exam– MS/ABC’s– Detailed neuro exam– Search for source of fever (in ED)
Febrile Seizure: managementFebrile Seizure: managementABCs and monitor VSCheck blood glucoseabort seizure if ongoing (benzodiazepine)
– IV/IM/PR administration
Cooling measuresTransport to appropriate hospital
Reference REMO Protocol P-10 Pediatric Seizures
Case 2Case 2
42 y/o WM reportedly had a seizure at a Phish concert. Friends think he takes Dilantin.
What more do you need to know?What do you look for on exam?What is your assessment and plan?
Epilepsy: ConsiderationsEpilepsy: Considerations
multiple different epilepsy syndromesbreakthrough vs noncomplianceprovoking factors
Epilepsy: statisticsEpilepsy: statistics
Affects 1.5-2.5 million people in US30-40% patients with epilepsy continue to
have breakthrough seizures despite appropriate medical management
Epilepsy: assessmentEpilepsy: assessment
History– determine:
intercurrent illness/trauma Sleep deprivation drug or etoh use drug drug interactions med compliance recent change in dosing regimen change in seizure pattern
Physical Exam– Evidence of injury– Detailed neuro exam
Epilepsy: managementEpilepsy: management
MS/ABC’sMonitor VS and check blood glucoseTreat any injuriesTransport to appropriate hospitalIV and ALS monitor:
– Multiple seizures– Single seizure without return to baseline state– Atypical seizure (type or pattern)
Reference REMO Protocols M-2 Active Seizures
Case 3Case 3
19 y/o female college student who “fell out” at a party. Witnesses describe generalized seizure activity. Confused/combative upon EMS arrival.
What more do you need to know?What do you look for on exam?What is your assessment and plan?
Differential ConsiderationsDifferential Considerations
Syncope Hyperventilation syndrome Prolonged breathholdling toxic and metabolic disorders
– ETOH abuse/withdrawal– hypoglycemia
other CNS event (TIA, migraine, narcolepsy) movement disorders (hemiballismus, tics) Psychiatric disorders (fugue state, panic attacks) Functional Disorders (pseudoseizure)
Characteristics of SeizureCharacteristics of Seizure
abrupt onsetbrief duration (90-120 sec)Altered mental status (except simple partial)purposeless activityunprovoked (except febrile)postictal state (except simple partial and
absence)
First Time Seizure: StatisticsFirst Time Seizure: Statistics
Rates of recurrence 23-71%Predictors of recurrence
– Etiology of seizure– EEG findings
Historical InformationHistorical Information
History vital in determining the appropriate ED approach– description of event– preceding aura– loss of bowel/bladder– duration of event– post ictal period– clinical context (precipitating factors?)
febrile illness head trauma sleep deprivation other stressor
– baseline seizure pattern
Initial AssessmentInitial Assessment
No longer seizing: recovery position, IV, glucose, medication history– preventative medications?
Is seizing still:– Airway assessment (npa, suction, ETT prn)– protect patient from self injury – pulseox, monitor, IV access, blood glucose
(hypoglycemia is the most common metabolic cause of sz, but can also be a result of prolonged sz…needs to be treated aggressively either way)
– abortive therapies
Detailed Physical ExamDetailed Physical Exam Done after cessation of seizure activity assess for injuries
– posterior shoulder dislocation common Temperature assessment Bedside glucose determination Cardiac Monitor Assess for presence of systemic disease, toxic exposure,
infection, focal neurologic event serial neurologic exams
– Todd’s paralysis: focal deficit following a seizure lasting less than 48 hours
Typical Physical Exam Typical Physical Exam FindingsFindings
HTN, tachycardia, tachypnea during seizure activity
incontinence, vomiting, tongue bitinglow grade temp common after generalized
seizure
First Time Seizure: First Time Seizure: ManagementManagement
MS/ABC’s Monitor VS and check blood glucose IV access (draw labs) Cardiac monitor Treat any injuries Transport to appropriate hospital No benzodiazepines unless seizure recurs or
continues
Reference REMO Protocols M-2 Active Seizures
Case 4Case 4
6 y/o WF presents s/p “seizure.” During transport EMS witnesses a generalized tonic-clonic event.
What more do you need to know?What do you look for on exam?What is your assessment and plan?
Status Epilepticus: Status Epilepticus: ConsiderationsConsiderations
continuous clinical or electrical seizure activity or repetitive seizures with incomplete neurological recovery for >30 min
Continuous seizure activity for >10min should be treated as if in SE (most seizures last 1-2 min)
impending SE if >3 tonic-clonic seizures within 24hrs
Generalized or Partial
Status Epilepticus: Status Epilepticus: ConsiderationsConsiderations
Generalized convulsive activity results in: hypoxia hyperpyrexia BP instability and cerebral dysautoregulation respiratory and metabolic acidosis hyperazotemia/hypokalemia/hyponatremia hyperglycemia followed by hypoglycemia marked elevations of prolactin, glucagon, growth
hormone and corticotropin rhabdomyolysis may produce myoglobinuria and renal
failure
Status Epilepticus: StatisticsStatus Epilepticus: Statistics
195,000 episodes in US annually 42,000 deaths annually in US 50% due to acute CNS insults (anoxia, TBI, CVA,
neoplasm, infection)– peds: fever/infection– elderly: cerebrovascular disease
20% in epileptic patients during med adjustment or due to noncompliance
30% undetermined etiology
Status Epilepticus: Status Epilepticus: AssessmentAssessment
HPI/AMPLEDetailed exam and history taking done once
seizure has been stopped and patient has been stabilized
Status Epilepticus: Status Epilepticus: ManagementManagement
Rapid Seizure control– Patients do better when seizure treated by EMS
Step 1:– ABC’s
NPA, OPA, ETT If RSI needed use only short acting paralytics
– blood glucose– Cardiac Monitor– IV access– HPI/PE
Further specific treatment based upon circumstance
Status Epilepticus: Status Epilepticus: ManagementManagement
Step 2: 1st line drugsStep 3: 2nd line drugsStep 4: 3rd line drugs
The longer the seizure continues;– The more difficult it is to stop – The more likely permanent CNS injury will
occur
Medication OptionsMedication Options
First line– diazepam (Valium) IV/ET/IO/PR– lorazepam (Ativan)IV/IN– midazolam (Versed)IV/IM/IN
Second line– phenytoin/fosphenytoin – phenobarbital
Lastly induction of anesthesia w. cont. EEG– Infusions of midazolam, diprivan, valproic acid,
pentobarbital– Inhaled isoflurane
Rectal Route of Rectal Route of AdministrationAdministration
• Surface area=200-400 cm2 (1/10,000 absorptive area of small intestine)• Highly vascularized• Passive diffusion
Rates of Diazepam Absorption by Various
Routes
Moolenaar F. Int J Pharma. 1980.
First Line AnticonvulsantsFirst Line AnticonvulsantsDRUG ADULT DOSE PEDS DOSE OTHER INFO
Diazepam .2mg/kg up to 20mg at 2mg/min
.2-.5mg/kg IV/IO or .5-1.0mg/kg PR up to 20mg
CNS/CV/Resp depression
Onset 1min
Lasts 20-30min (longer PR)
Lorazepam .1mg/kg IV max 10mg at 2mg/min
**Intranasal use promising
.05-.1mg/kg IV
**Intranasal use promising
CNS/CV/Resp depression
Onset 2min
Lasts >12hrs
Midazolam .1mg/kg IV up to 10mg at 1mg/min or .2mg/kg IM
**Intranasal use promising
.15mg/kg IV
.2mg/kg IM
**Intranasal use promising
Less depression
Onset 1min
Short duration
Second Line AnticonvulsantsSecond Line AnticonvulsantsDRUG ADULT DOSE PEDS DOSE OTHER INFO
Phenytoin 20mg/kg IV at 50mg/min
20mg/kg IV at 1mg/kg/min
Hypotension, arrhythmias Onset 10-30min
Long acting
Fosphenytoin 15-20PE/kg IV at 150mg/min or 20PE/kg IM
10-20PE/kg IV at 3mg/kg/min or 20PE/kg IM
Can be given faster
Expensive
Same times once given
Phenobarbital 10-20mg/kg IV at 30mg/min or 20mg/kg IM
May rpt to 40mg/kg total
Same as adult Resp/CV depression
Rapid onset, long acting
Third Line AnticonvulsantsThird Line AnticonvulsantsDRUG ADULT PEDS OTHERMidazolam .15mg/kg IVthen
1mcg/kg/min
up 1mcg/kg/min q15
As adult CNS/Resp/CV depression
Propofol 1-3mg/kg IV then 2-10mg/kg/h
Caution in <12yrs (reports of met. Acidosis)
CNS/Resp/CV depression
Valproic Acid 20-40mg/kg IV over 5min then 5mg/kg/h
As adult hypotension
Pentobarbital 5mg/kg IV at 25mg/min
As adult Titr.to EEG
ETT/CV support
Isoflurane Via gen’l ETT anesthesia
As adult Titr. to EEG
ETT/CV support
ConclusionsConclusions
Seizures are common presenting problems to EMS.
Status epilepticus must be treated rapidly to avoid significant morbidity.
Familiarity with protocols and medication options is crucial.
Questions?Questions?
ReferencesReferences
American College of Emergency Physicians: Clinical policy for the initial approach to patients presenting with a chief complaint of seizure who are not in status epilepticus. Ann Emerg Med. May 1997;29:706-724.
ACEP, AAN, AANS, ASN: Practice parameter: Neuroimaging in the emergency patient presenting with seizure (summary statement). Ann Emerg Med. 1996;28:114-118.
Smith, BJ. Treatment of Status epilepticus. Neurologic Clinics. May 2001;19:2
Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emergency Medicine Clinics of North America. Feb 1999;17:1
References cont’dReferences cont’d Goetz. Epileptic Seizures. Textbook of Clinical Neurology, 1st
ed. WB Saunders 1999. pp1062-1079 Pollack CV. Seizures. Rosen’s Emergency Medicine: Concepts
and Clinical Practice, 5th Ed. Mosby 2002. Pp145-149 Hanhan UA, Fiallos MR, Orlowski JP. Status Epilepticus.
Pediatric Clinics of North America. Jun 2001;48:3 Lahat E, Goldman M, Barr J, et al. Comparison of intranasal
midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study. BMJ. July 200;321:83-86
Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children. Neurology. Sept 2000;55:5