Seizures

A. Status epilepticus

A seizure that lasts for more than 30 minutes, or seizures that recur for more than 30 minutes without regaining consciousness in between. This is an emergency.

1. Initial assessment: ABCs (airway, breathing, cardiac), O₂ sats, coma exam (see Coma and Brain Death, p. 29), EKG, IV access, and draw labs. Coma exam can almost always be done before intubation and sedation.
2. Initial rx:
- a. Thiamine, glucose: 100 mg IV, 50% dextrose 50 cc, naloxone.
- b. Lorazepam (Ativan): 2 mg IV q2min × 5, or diazepam (Valium) 5 mg IV q3min × 4 while starting DPH load.
  - 1) Pediatric dosing: Diazepam 0.2 mg/kg IV at 1 mg/min, to max. of 10 mg. Or lorazepam 0.1 mg/kg IV under age 12, 0.07 mg/kg over age 12.
- c. IV ACD: Avoid IV phenytoin if possible. Options:
  - 1) Fosphenytoin: see p. 162. Load 1000 mg PE (PE = phenytoin equivalent doses) IV/IM, at <150 mg/min. Cardiac monitor; check BP q min. Pediatric dose = 20 mg/kg IV at 0.5 mg/kg/min.
  - 2) Valproate: Load 1 g over 15-20 min (20 mg/kg). No immediate SEs to follow; check ammonia/LFTs in follow-up. Therapeutic level = 50-100.
3. Full assessment: H&P (see below), intubate if necessary, check labs, stat head CT. Consider lumbar puncture + Abx if pt. is febrile or has never seized before. Consider emergent EEG if pt. is comatose to rule out nonconvulsive status.
4. Second-line rx: Usually require intubation and arterial line (see p. 222) for BP monitoring.
- a. Phenobarbital (Luminal): 20 mg/kg IV (100 mg/min) if still seizing after 40 min despite DPH and lorazepam.
- b. Pentobarbital (Nembutal): 5 mg/kg IV load if still seizing after phenobarbital. Titrate dose (0.3-9 mg/kg/h) to obtain 3- to 15-sec periods of burst suppression on EEG.
- c. Midazolam (Versed): 0.2 mg/kg IV loading dose as alternative to phenobarbital or pentobarbital. Titrate dose (0.1-0.4 mg/kg/h) to get burst on EEG.
- d. Supportive care: Pressors if necessary. Cool pt. if febrile. Stop ACD drip once a day to see underlying EEG rhythm.
5. Special cases:
- a. Partial status epilepticus: May be confused with tremor.
- b. Nonconvulsive status epilepticus: Usually there is some focal motor activity such as rhythmic blinking; rarely is there merely altered mental status. Nearly all pts. in nonconvulsive status are known epileptics. A test of 1-4 mg lorazepam IV/SL/PO should cause improvement (but may also improve catatonia).
- c. Pyridoxine (B₆) deficiency: Consider giving pyridoxine 1 g IV or more if pt. is on isoniazid.

B. Seizure H&P

Aura, behavior during seizure, postictal period, h/o previous seizures or status epilepticus, drugs tried, nocturnal tongue biting or incontinence, febrile seizures as child, head injury, recent alcohol or other drugs, illness, sleep deprivation, relation to menstruation.

C. DDx of seizures

Syncope, myoclonus, tremor, pontine rigors, pseudoseizure, narcolepsy.