Template:Seizure actively seizing management: Difference between revisions
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**[[Fosphenytoin]] IV 20-30 mg/kg at 150 mg/min (may also be given IM) | **[[Fosphenytoin]] IV 20-30 mg/kg at 150 mg/min (may also be given IM) | ||
***Contraindicated in pts w/ 2nd or 3rd degree AV block | ***Contraindicated in pts w/ 2nd or 3rd degree AV block | ||
***Avoid phenytoin or fosphenytoin in suspected toxicology case | ***Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade | ||
**[[Valproic acid]] IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy) | **[[Valproic acid]] IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy) | ||
*Refractory medications | *Refractory medications | ||
Revision as of 08:53, 15 February 2020
Seizure Precautions
- Protect patient from injury
- If possible, place patient in left lateral position to reduce risk of aspiration
- Do not place bite block!
- Jaw thrust, a NPA and oxygen may be required
- An IV line should be placed
Medications
- Benzodiazepine (Initial treatment of choice)[1]
- Secondary medications
- ESETT trial[3] compared second line antiseizure medications and they all are equally efficacious. Therefor may be best to use the one with least side effects [4] which is Levetiracetam
- Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
- Phenytoin IV 18 mg/kg at ≤ 50 mg/min
- Fosphenytoin IV 20-30 mg/kg at 150 mg/min (may also be given IM)
- Contraindicated in pts w/ 2nd or 3rd degree AV block
- Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
- Valproic acid IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy)
- Refractory medications
- Propofol 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
- Midazolam 0.2mg/kg, then infusion of 0.05-2mg/kg/hr OR
- Ketamine loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr[5]
- Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[6]
- Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[7]
- Then continuous infusion at 0.5-4.0 mg/kg/hr
- Dose adjusted to suppression-burst pattern on continuous EEG
- Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[8]
- Others
- Carbamazepine 8 mg/kg oral suspension, single oral load
- Gabapentin 900 mg/day oral at 300 mg tid for 3 days
- Lamotrigine 6.5 mg/kg single oral load
Other Considerations
- Secondary causes of seizure (e.g. hyponatremia, hypoglycemia, INH toxicity, ecclampsia)
- Nonconvulsive seizures or status epilepticus - get EEG
- ↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
- ↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
- ↑ Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
- ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
- ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
- ↑ Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
- ↑ Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
- ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.