The Neurologic Emergencies Debate:The Neurologic Emergencies Debate:

Case Studies in Seizures and StrokeCase Studies in Seizures and Stroke

June 17, 2005June 17, 2005

Sponsored by an unrestricted educational grant from UCB PharmaSponsored by an unrestricted educational grant from UCB Pharma

PanelistsPanelists

• Andy Jagoda, Mount Sinai: ModeratorAndy Jagoda, Mount Sinai: Moderator• Steve Huff, University of VirginiaSteve Huff, University of Virginia• Brad Bunney, University of Illinois at ChicagoBrad Bunney, University of Illinois at Chicago• John Decerce, University of Florida, JacksonvilleJohn Decerce, University of Florida, Jacksonville• James Meschia, Mayo Clinic JacksonvilleJames Meschia, Mayo Clinic Jacksonville

What is your backgroundWhat is your background

a.a. Emergency medicine Emergency medicine

b.b. Neurology Neurology

c.c. PAPA

d.d. NurseNurse

e.e. OtherOther

Do you feel comfortable with your Do you feel comfortable with your neurologic exam?neurologic exam?

A.A. YesYes

B.B. NoNo

Case 1:Case 1:

ALS call to medical control: 9 pmALS call to medical control: 9 pm

• ““We have a 36 year old drunk found on the street”We have a 36 year old drunk found on the street”• No known traumaNo known trauma• Intermittently seizing for the past 10 minutes. Intermittently seizing for the past 10 minutes. • ETA is 20 minutes. ETA is 20 minutes. • What should we do?What should we do?

History and physicalHistory and physical

• History: None available. History: None available. • Perscriptions for depakote, clonidine, isoniazid in Perscriptions for depakote, clonidine, isoniazid in

his pockethis pocket• BP 180 / 90, P 110, RR 20, POx 96% RABP 180 / 90, P 110, RR 20, POx 96% RA• Head atraumaticHead atraumatic• Pupils 2 mm with tonic deviation to the rightPupils 2 mm with tonic deviation to the right• Mouth with blood from ? tongue lacerationMouth with blood from ? tongue laceration• Moving all four extremitiesMoving all four extremities

Question 1Question 1

Would you recommend that the patient be put Would you recommend that the patient be put in a cervical collar?in a cervical collar?

a.a. YesYes

b.b. NoNo

Incidence of SeizuresIncidence of Seizures

• 10% of all pediatric ambulance calls.10% of all pediatric ambulance calls.11

• 5% of all ambulance calls received by a 911 5% of all ambulance calls received by a 911 center in Cleveland, Ohio.center in Cleveland, Ohio.22

Question 2Question 2

Do you recommend empiric dextrose?Do you recommend empiric dextrose?

a.a. YesYes

b.b. NoNo

Emergency Department Adult Seizure EtiologyEmergency Department Adult Seizure Etiology

• Only 50% with known final diagnosisOnly 50% with known final diagnosis• Acute symptomatic ~50% of ED seizuresAcute symptomatic ~50% of ED seizures• 44% with prior seizure history44% with prior seizure history• 40% alcohol related40% alcohol related

• ½ of these are alcohol withdrawal½ of these are alcohol withdrawal• Medication noncompliance ~30%Medication noncompliance ~30%

ED Adult New Onset Seizure EtiologyED Adult New Onset Seizure Etiology

Young adultsYoung adults• Traumatic brain injuryTraumatic brain injury• Alcohol abuse / withdrawalAlcohol abuse / withdrawal• Illicit drug useIllicit drug use• Brain tumorBrain tumor• MetabolicMetabolic

• HypoglycemiaHypoglycemia• PregnancyPregnancy

Older adults Older adults • Cerebrovascular diseaseCerebrovascular disease• Brain tumorBrain tumor• Alcohol withdrawalAlcohol withdrawal• Metabolic disordersMetabolic disorders

• UremiaUremia• Liver failureLiver failure• Electrolyte abnormalitiesElectrolyte abnormalities• HypoglycemiaHypoglycemia

• Subdural hematomaSubdural hematoma

Question 3Question 3

EMS is unable to secure an IV. Which of the EMS is unable to secure an IV. Which of the following do you recommend?following do you recommend?

a.a. Rectal diazepamRectal diazepam

b.b. IM diazepamIM diazepam

c.c. IM midazolamIM midazolam

d.d. IM fosphenytoinIM fosphenytoin

Question 4Question 4

Where should this patient be transported to? Where should this patient be transported to?

a)a) Closest hospitalClosest hospital

b)b) Trauma centerTrauma center

c)c) Stroke centerStroke center

9:30. Arrives in ED9:30. Arrives in ED

Vital signs unchanged. Rectal temp – 99Vital signs unchanged. Rectal temp – 99º º F Blood sugar 160. F Blood sugar 160. 20 g IV established in the right hand. Patient begins having 20 g IV established in the right hand. Patient begins having a generalized tonic clonic seizure. What would you order?a generalized tonic clonic seizure. What would you order?

a.a. Diazepam 5 mg IV Diazepam 5 mg IV b.b. Lorazepam 2 mg IVLorazepam 2 mg IVc.c. Phenytoin 20 mg / kg IV over 20 minPhenytoin 20 mg / kg IV over 20 mind.d. Fosphenytoin 20 PE / kg over 10 minutesFosphenytoin 20 PE / kg over 10 minutese.e. Valproic acid 20 mg / kg IV over 5 minValproic acid 20 mg / kg IV over 5 minf.f. OtherOther

9:40. Patient continues to seize9:40. Patient continues to seize

Which of the following is your next interaction:Which of the following is your next interaction:

a.a. Phenytoin 20 mg / kg IV over 20 minPhenytoin 20 mg / kg IV over 20 min

b.b. Fosphenytoin 20 PE / kg IV over 10 minFosphenytoin 20 PE / kg IV over 10 min

c.c. Valproic acid 20 mg / kg IV over 5 minValproic acid 20 mg / kg IV over 5 min

d.d. Phenobarbital 20 mg / kgPhenobarbital 20 mg / kg

e.e. Pyridoxime (BPyridoxime (B66) 5 gm) 5 gm

9:55. Patient continues to seize9:55. Patient continues to seize

Nurse notes that phenytoin infusion has infiltrated into the Nurse notes that phenytoin infusion has infiltrated into the hand. What do you recommend?hand. What do you recommend?

a.a. Stop the infusion and administer the rest IMStop the infusion and administer the rest IM

b.b. Continue infusion but apply warm compresses to Continue infusion but apply warm compresses to promote absorptionpromote absorption

c.c. Inject HCO3 into the site to buffer the infiltrationInject HCO3 into the site to buffer the infiltration

d.d. Stop the IV, elevate the hand, call risk managementStop the IV, elevate the hand, call risk management

10:45. Patient continues to intermittently 10:45. Patient continues to intermittently seize without regaining consciousnessseize without regaining consciousness

What is your third line agent for managing patients in status What is your third line agent for managing patients in status epilepticus?epilepticus?

a.a. Phenobarbital 20 mg / kg Phenobarbital 20 mg / kg

b.b. Valproic acid 20 mg / kgValproic acid 20 mg / kg

c.c. Midazolam drip 5 mg / hourMidazolam drip 5 mg / hour

d.d. Pentobarbital 5 mg / kgPentobarbital 5 mg / kg

e.e. Propofol 5 mg / kg Propofol 5 mg / kg

f.f. Paralyze and intubateParalyze and intubate

11:00. Decision is made to intubate the 11:00. Decision is made to intubate the patient using RSIpatient using RSI

Which of the following premedications would you Which of the following premedications would you use?use?

a.a. NoneNoneb.b. LidocaineLidocainec.c. Lidocaine plus fentanylLidocaine plus fentanyld.d. Lidocaine plus fentanyl plus a defasciculating Lidocaine plus fentanyl plus a defasciculating

dose of vecuroniumdose of vecuronium

13:00 No additional medications given; 13:00 No additional medications given; patient remains unresponsivepatient remains unresponsive

Would you request a STAT EEG on this patient?Would you request a STAT EEG on this patient?

a)a) YesYes

b)b) NoNo

Are you able to obtain a STAT EEG in your EDAre you able to obtain a STAT EEG in your ED

a)a) YesYes

b)b) NoNo

Nonconvulsive Status EpilepticusNonconvulsive Status Epilepticus

• NCSE vs SCSENCSE vs SCSE• Prognosis worse with SCSEPrognosis worse with SCSE

• Clinical characteristicsClinical characteristics• Mild cognitive deficits to comaMild cognitive deficits to coma**

• Incidence: 14% after CSEIncidence: 14% after CSE****• Diagnosis: Clinical and EEGDiagnosis: Clinical and EEG• TreatmentTreatment

* * Tomson. Epilepsia 1992;33:829-835Tomson. Epilepsia 1992;33:829-835** DeLorenzo. Epilepsia 1998; 39:833-840** DeLorenzo. Epilepsia 1998; 39:833-840

14:45. Patient returns from radiology14:45. Patient returns from radiology

Medical student reads the CT as “abnormal”Medical student reads the CT as “abnormal”

Patient is transported to a hospital with Patient is transported to a hospital with neurosurgical capabilities. One year later, the neurosurgical capabilities. One year later, the patient has right sides weakness, significant patient has right sides weakness, significant behavioral and cognitive dysfunction.behavioral and cognitive dysfunction.

• Family sued EMS, nurse, and physician for negligenceFamily sued EMS, nurse, and physician for negligence• Was EMS negligent to not have taken the patient to a Was EMS negligent to not have taken the patient to a

trauma center? trauma center? • Was nursing negligent to allow intravenous phenytoin Was nursing negligent to allow intravenous phenytoin

through a 20 gauge hand IVthrough a 20 gauge hand IV• Was the physician negligent:Was the physician negligent:

• Delay in controlling the seizure Delay in controlling the seizure • Delay in obtaining the diagnostic CT? Delay in obtaining the diagnostic CT?