Status Epilepticus
Background
Definition
>5 min of seizure activity without response to treatment // recurrent seizure without return to baseline mental status
mortality is 22%
can be convulsive or non-convulsive (tricky)
non-convulsive can be change in behavior/complete loss of consciousness with signs such as twitching/blinking/eye deviation
eeg shows continuous epileptiform discharges
get a fingerstick/BGM
ABCs
try to place in left lateral decubitus position (can aspirate)
place a NC/NRB/LMA early
intubate if benzos are not breaking the seizure
this is obviously at the discretion of the team, best to consider all circumstances…intubate if you need to
standard RSI is fine but if at all possible, then try to use induction agent only
paralytic can mask seizures and put them in non-convulsive state
if must use, then succ is quicker on/off
IV line for meds (IO/IM/IN if desperate)
Treatment
First line: Benzos
Not controversial, should be first line
Versed
If no IV, then give versed IM or IN
Ativan
Valium
Try to use weight based dosing the way we do in peds
*if no response after 4 min, give another dose
Second line: depends
Traditionally:
Phenytoin 20 mg/kg IV
Fosphenytoin 20-30 mg/kg IV (/IM)
Keppra 40 mg/kg IV (max 4.5g)
BUT, consider anesthetic instead
Propofol 1.5-2mg/kg IV
followed by 20-200mcg/kg/min drip
can add Ketamine 1mg/kg IV to propofol
Phenobarb 15-20 mg/kg over 10 min
followed by 5-10mg/kg after 10 min
followed by .5-4mg/kg/hr drip
May not be as readily available as propofol/ketamine is in your ED
**still hang the phenytoin/keppra even though you’re giving them an anesthetic, will need long term anticonvulsant on board anyway
Eclampsia
give 4g magnesium IV
**management slightly different in peds
Find the cause
infectious
eclampsia
INH
Give pyridoxine (1g for every 1g of INH taken….or can just give the max of 5g empirically)
Hyponatremia
3% NaCl 2ml/kg q 10 min
if in a pinch, then give amp of bicarb (consists of 6% NaCl) which will always be available somewhere in a code cart
