Difference between revisions of "Template:Seizure actively seizing management"

(Medications)
(Medications)
 
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===Medications===
 
===Medications===
 
*[[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 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
+
**[[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>
**[[Lorazepam]] IV 2 mg or 0.1 mg/kg
+
***May also be given IN at 0.2 mg/kg, max 10 mg
 +
***OR buccal at 0.3 mg/kg, max 10 mg
 +
**[[Lorazepam]] IV 2-4 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)
 
**[[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
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**[[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
***Avoid phenytoin or fosphenytoin in suspected toxicology case
+
***Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
**[[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, max 3000 mg (avoid 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'''

Latest revision as of 08:54, 15 February 2020

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]
    • Midazolam IM 10 mg (> 40 kg), 5mg (13-40 kg), or 0.2 mg/kg[2]
      • May also be given IN at 0.2 mg/kg, max 10 mg
      • OR buccal at 0.3 mg/kg, max 10 mg
    • Lorazepam IV 2-4 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
    • ESETT trial[3] compared second line antiseizure medications and they all are equally efficacious. Therefor may be best to use the one with least side effects [4] which is Levetiracetam
    • Levetiracetam IV 60 mg/kg, max 4500 mg/dose, or 1500 mg oral load (preferred in pregnancy)
    • 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
      • Avoid phenytoin or fosphenytoin in suspected toxicology case due to sodium channel blockade
    • Valproic acid IV 20-40 mg/kg at 5 mg/kg/min, max 3000 mg (avoid 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[5]
    • Lacosamide IV 400 mg IV loading dose over 15 min, then maintenance dose of 200 mg q12hrs PO/IV[6]
    • Phenobarbital IV 15-20 mg/kg at 50-75 mg/min[7]
      • 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)[8]
  • Others

Other Considerations

  • 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
  • Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
  • PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  • 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.