00:01
How about the treatment
for status epilepticus?
Let's walk through
what we do emergently.
00:06
And with our initial investigations
and long-term treatment
to stop this continuous
seizure activity.
00:12
We'll start with
the first five minutes.
00:14
This is the stabilization phase,
and we do the ABCs.
00:17
We focus on airway,
breathing, circulation,
and any disability or
neurologic exam abnormalities.
00:24
We need to make sure
the patient has an open airway,
That airway is clear of blood or
sputum production or those things.
00:31
We focus on breathing
and often provide
oxygen supplementation,
and don't tend to have
circulatory arrest
unless there's another
potential cause of the status.
00:40
But those ABCs are
important for any patient
who's presenting with a
life threatening emergency.
00:47
The second piece
is to look at the time.
00:49
And time the seizure from its onset
and monitor vital signs rigorously
during that first few minutes
of the seizure.
00:56
The first three minutes
feel like three hours.
00:59
Though most seizures
90% to 95% of seizures
will resolve spontaneously
within the first three minutes.
01:06
We assess oxygenation.
01:08
Give oxygen via
nasal canula, facemask,
and may consider intubation
if there is respiratory dysfunction
or concern for respiratory arrest,
or assistance is needed.
01:18
we initiate EKG or ECG monitoring
for all these patients,
either by EMS in the field,
or in route, in an ambulance,
or in the emergency department.
01:27
And then we typically think
about collecting some early tests
that can help
to intervene for patients
who may have an exacerbation
that's causing this
continuous seizure activity.
01:37
Hypoglycemia, even hyperglycemia
can cause seizures,
and so we collect a fingerstick,
blood glucose, and intervene.
01:44
The intervention is different
for children by age and in adults,
we think about both D50.
01:49
To to rescue hypoglycemia,
as well as intravenous thiamine.
01:55
And then the last step during
the stabilization phase
is to attempt IV access,
collect electrolytes
for blood testing,
hematology,
or toxicology screening.
02:06
And if appropriate,
check anticonvulsant levels
for patients who may be
on anti-epileptic medicines
and have a diagnosis of epilepsy.
02:14
So that stabilization phase
is critical.
02:16
We think about it in the
first zero to five minutes,
but maybe in the first zero to two,
or three minutes for patients
who suffer a new onset of seizure
in a hospital setting.
02:27
If the seizure does continue,
we consider
the initial therapy phase
if the seizure does not continue,
then the patient
proceeds to symptomatic
medical management and care.
02:37
During this initial therapy phase,
there are a number of interventions
that are done to stop
the seizure from occurring.
02:44
Benzodiazepines are
the initial therapy of choice
for aborting a seizure,
and for stopping
status epilepticus.
02:52
We typically choose
one of several agents
including intramuscular midazepam,
intravenous lorazepam,
and intravenous diazepam.
03:02
These are equivalent medicines
and sometimes it depends
on the availability of those.
03:06
We want to get them started
and get them started quickly
to abort that seizure.
03:11
If none of these agents
are available,
we can consider
intravenous phenobarb,
as well as rectal diazepam,
or intranasal midazolam.
03:19
And I mentioned those
because that can be used
by patients or caregivers
at home.
03:23
In a chronic epileptic who
has breakthrough seizures,
and we really want to prevent
multiple recurrent seizures.
03:28
Rectal administration of diazepam,
or intranasal midazolam
can be performed at home.
03:35
If the seizure continues,
we repeat the intravenous,
intramuscular, intranasal
benzodiazepine
up to three times
spaced out about
every three to five minutes.
03:46
If the seizure continues, we move
into the second line therapy phase.
03:50
If the seizure does not continue,
and abates after abortion
with the benzodiazepine,
we work on symptomatic
medical management.
03:58
And in many of those patients,
we continue on
to second line therapy
to stop the seizure from recurring
after it has initially
been aborted.
04:10
During the second line
therapy phase,
we think about a number
of medicines, anti-epileptics,
and we'll talk about three
that are used to stop the seizure.
04:18
These are anticonvulsant
medications.
04:21
And we tend to think
of one of three medicines.
04:24
Intravenous fosphenytoin,
intravenous valproic acid
and intravenous levetiracetam.
04:31
These are important
medicines to remember.
04:33
These are the definitive treatments
for status epilepticus.
04:37
And their doses
are sometimes tested.
04:39
And are things we need to know
in this emergent setting
to manage these patients.
04:43
Fosphenytoin is given
at a dose of 20 mg per kg.
04:47
Valproic acid is given
an a dose of 40 mg per kg,
and levetiracetam has given
it a dose of 60 mg per kg.
04:54
And we'll talk about those
a little later
in the lecture as well.
04:57
If none of these are available,
we can consider
intravenous phenobarbital.
05:01
Historically, this was the
medicine used as the first choice
for status epilepticus.
05:05
But it has been replaced by
these newer agents.
05:09
So again,
then we reevaluate the patient
after administration of that agent.
05:13
And if the seizure continues,
we move into the
third phase of treatment,
and if not, we move to symptomatic
management of the patient,
at that time.
05:21
There's no clear evidence or guide
about what to do
in this third phase
of treatment.
05:26
This is for seizures
that continue
after that initial
definitive treatment.
05:31
Typically, we would consider
a second line therapy.
05:34
So a fosphenytoin
was selected, initially.
05:36
We'd move to valproic acid,
or levetiracetam.
05:39
If levetiracetam
was administered initially,
we'd moved to fosphenytoin
or valproic acid.
05:45
And that's the initial management
of status epilepticus.