Académique Documents
Professionnel Documents
Culture Documents
Seizures
Deb Funk, M.D., NREMT-P
Medical Director;
Albany MedFLIGHT
Saratoga EMS
Goals
Review
Discuss
Definitions
Seizure:
Epilepsy:
status
Epidemiology
6-10%
visits
incidence
Classification
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
Seizure
most
common
vague prodromal symptoms
tonic phase
trunk flexion-->extension, eyes deviate up,
mydriasis, vocalization
clonic
phase
Generalized: Tonic-Clonic
contd
loss
Pathophysiology of Seizures
in
Pathophysiology contd
typically
self limited
terminate
Case 1
2
What
of children
most common pediatric seizure
30% 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 risk
2-9% develop afebrile seizures
Physical
Exam
MS/ABCs
Detailed neuro exam
Search for source of fever (in ED)
and monitor VS
Check blood glucose
abort seizure if ongoing (benzodiazepine)
IV/IM/PR administration
Cooling
measures
Transport to appropriate hospital
Case 2
42
What
Epilepsy: Considerations
multiple
Epilepsy: statistics
Affects
Epilepsy: 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: management
MS/ABCs
Monitor
Case 3
19
What
Differential 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 Seizure
abrupt
onset
brief duration (90-120 sec)
Altered mental status (except simple partial)
purposeless activity
unprovoked (except febrile)
postictal state (except simple partial and
absence)
of recurrence 23-71%
Predictors of recurrence
Etiology of seizure
EEG findings
Historical Information
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 Assessment
No
Is
seizing still:
abortive therapies
Temperature
assessment
Bedside glucose determination
Cardiac Monitor
Assess for presence of systemic disease, toxic exposure,
infection, focal neurologic event
serial neurologic exams
Todds paralysis: focal deficit following a seizure lasting less than
48 hours
Case 4
6
Status Epilepticus:
Considerations
continuous
Status Epilepticus:
Considerations
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
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%
Status Epilepticus:
Assessment
HPI/AMPLE
Detailed
Rapid
Status Epilepticus:
Management
Seizure control
Step
1:
ABCs
blood glucose
Cardiac Monitor
IV access
HPI/PE
Status Epilepticus:
Management
Step
occur
Medication Options
First
line
Second
line
phenytoin/fosphenytoin
phenobarbital
Lastly
Rectal Route of
Administration
Rates of Diazepam
Absorption by Various
Routes
ADULT DOSE
PEDS DOSE
Diazepam
.2mg/kg up to
20mg at 2mg/min
Lorazepam
.1mg/kg IV max
10mg at 2mg/min
**Intranasal use
promising
.05-.1mg/kg IV
.1mg/kg IV up to
10mg at 1mg/min
or .2mg/kg IM
**Intranasal use
promising
.15mg/kg IV
.2mg/kg IM
Midazolam
**Intranasal use
promising
**Intranasal use
promising
OTHER INFO
CNS/CV/Resp
depression
Onset 2min
Lasts >12hrs
Less depression
Onset 1min
Short duration
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
10-20PE/kg IV
at 150mg/min or at 3mg/kg/min
20PE/kg IM
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
Resp/CV
depression
Rapid onset,
long acting
Same as adult
DRUG
ADULT
PEDS
OTHER
Midazolam
Propofol
1-3mg/kg IV
then 210mg/kg/h
Caution in
CNS/Resp/CV
<12yrs (reports depression
of met. Acidosis)
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
As adult
Titr. to EEG
ETT/CV support
CNS/Resp/CV
depression
Conclusions
Seizures
to EMS.
Status epilepticus must be treated rapidly to
avoid significant morbidity.
Familiarity with protocols and medication
options is crucial.
Questions?
References
References contd