Template:Seizure actively seizing management: Difference between revisions
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**[[Diazepam]] IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg) | **[[Diazepam]] IV 0.15-0.2 mg/kg (up to 10 mg) or PR 0.2-0.5 mg/kg (up to 20 mg) | ||
*Secondary medications | *Secondary medications | ||
**[[Phenytoin]] IV 18 mg/kg at ≤ 50 mg/min | |||
**[[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 | ||
**[[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) | ||
**[[Levetiracetam]] IV 60 mg/kg, max 4500 mg/dose (preferred in pregnancy) | **[[Levetiracetam]] IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy) | ||
*Refractory medications | *Refractory medications | ||
**[[Propofol]] 2-5mg/kg, then infusion of 2-10mg/kg/hr '''OR''' | **[[Propofol]] 2-5mg/kg, then infusion of 2-10mg/kg/hr '''OR''' | ||
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***Dose adjusted to suppression-burst pattern on continuous EEG | ***Dose adjusted to suppression-burst pattern on continuous EEG | ||
**Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref> | **Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref> | ||
*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=== | ===Other Considerations=== | ||
*Secondary causes of seizure (e.g. [[hyponatremia]], [[hypoglycemia]], [[INH toxicity]], [[ecclampsia]]) | *Secondary causes of seizure (e.g. [[hyponatremia]], [[hypoglycemia]], [[INH toxicity]], [[ecclampsia]]) | ||
*Nonconvulsive seizures or status epilepticus - get EEG | *Nonconvulsive seizures or status epilepticus - get EEG | ||
Revision as of 21:02, 2 September 2019
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
- 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
- Valproic acid IV 20-40 mg/kg at 5 mg/kg/min (avoid in pregnancy)
- Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred 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[3]
- Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[4]
- Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[5]
- 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)[6]
- 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
- ↑ 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.