Template:Seizure actively seizing management: Difference between revisions

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**Do not place bite block!
**Do not place bite block!
*[[Benzodiazepine]] (Initial treatment of choice)<ref>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.</ref>
*[[Benzodiazepine]] (Initial treatment of choice)<ref>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.</ref>
**[[Midazolam]] IM 10mg (>40kg), 5mg (13-40kg), or 0.2mg/kg<ref>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</ref> - may also be given IN
**[[Midazolam]] IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg<ref>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</ref> - may also be given IN
**[[Lorazepam]] IV 2mg or 0.1mg/kg
**[[Lorazepam]] IV 2 mg or 0.1 mg/kg
**[[Diazepam]] IV 0.15-0.2mg/kg (up to 10mg) or PR 0.2-0.5mg/kg (up to 20mg)
**[[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
**[[Fosphenytoin]] IV 20-30mg/kg at 150mg/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 20-40mg/kg at 5mg/kg/min  
**[[Valproic acid]] IV 20-40 mg/kg at 5 mg/kg/min  
**[[Levetiracetam]] IV 60mg/kg, max 4500mg/dose
**[[Levetiracetam]] IV 60 mg/kg, max 4500 mg/dose
**[[Phenobarbital]] IV 20mg/kg at 50-75mg/min (be prepared to intubate)
*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'''
**[[Midazolam]] 0.2mg/kg, then infusion of 0.05-2mg/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<ref>Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.</ref>
**[[Ketamine]]  loading dose 0.5 to 3 mg/kg, followed by infusion of 0.3 to 4 mg/kg/hr<ref>Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.</ref>
**[[Lacosamide]] IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV<ref>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.</ref>
**[[Phenobarbital]] IV 15-20 mg/kg at 50-75 mg/min<ref>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.</ref>
***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)<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>
*Consider
*Consider
**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 19:15, 24 June 2017

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Benzodiazepine (Initial treatment of choice)[1]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[2] - may also be given IN
    • Lorazepam IV 2 mg or 0.1 mg/kg
    • 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
    • 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
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose
  • 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]
  • Consider
  1. ↑ 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.
  2. ↑ 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
  3. ↑ Legriel S, Oddo M, and Brophy GM. What’s new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  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.
  5. ↑ 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.
  6. ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
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