Transcript FERNE Template

Optimizing Seizure
and SE Patient
Management in the
Emergency
Department
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Professor
Department of Emergency Medicine
University of Illinois College of Medicine
Chicago, IL
Edward P. Sloan, MD, MPH
Attending Physician
Emergency Medicine
University of Illinois Hospital
Our Lady of the Resurrection Hospital
Chicago, IL
Edward P. Sloan, MD, MPH
Disclosures
• NovoNordisk, King Pharmaceuticals,
UCB Pharma Advisory Boards
• Eisai Speakers’ Bureau
•
•
•
•
ACEP Clinical Policies Committee
ACEP Scientific Review Committee
Executive Board, FERNE
FERNE support by Abbott, Eisai, Pfizer,
UCB
Edward P. Sloan, MD, MPH
www.ferne.org
Edward P. Sloan, MD, MPH
Board Chairman and President
FERNE
Chicago, IL
Edward P. Sloan, MD, MPH
Overview
Mission Statement
• Patients with neurological
emergencies deserve quality
emergency care.
• Quality scientific research.
• Case-oriented, evidence-based medical
education on optimal acute neurological
care.
• Use of technology to break down space
and time barriers.
Edward P. Sloan, MD, MPH
• Advocacy.
www.ferne.org
Edward P. Sloan, MD, MPH
Today’s Agenda
• Present a clinical case
• Review seizure and SE clinical data
• Discuss ED management
• Provide fosphenytoin data
• Consider fosphenytoin use
• Examine the patient outcome
• Close with a bonus case
Edward P. Sloan, MD, MPH
A Clinical Case
Edward P. Sloan, MD, MPH
Patient EMS Data
• 50?? yo male John Doe
• Generalized tonic-clonic seizure
• Chicago Fire Department
• Diazepam 5 mg IM, 15 mg IV
• Seizure continuous for 15 minutes +
• EMS to ED
• No change in status
Edward P. Sloan, MD, MPH
Patient Clinical History
• Unknown meds
• Unknown medical history
• Hx Needs surgery next month ??
• EtOH ??
• Does not appear to be homeless
• Accucheck 119
Edward P. Sloan, MD, MPH
ED Presentation
• Facial and shoulder twitching R
• Pt with gurgling BS
• Nasopharyngeal airway
• No evidence of trauma or toxicity
• IV access in neck
• Seizure persists x minutes
Edward P. Sloan, MD, MPH
Seizure/SE
Clinical Data
Edward P. Sloan, MD, MPH
Sz Epidemiology:
• Epilepsy seen in 1/150
people
• For each epilepsy pt, 1
ED visit every 4 years
• 1-2% of all ED visits
• Significant costs
Edward P. Sloan, MD, MPH
Seizure Mechanism:
• Sz = abnormal neuronal
discharge with recruitment
of otherwise normal
neurons
• Loss of GABA inhibition
Edward P. Sloan, MD, MPH
Seizures
Seizure Classification:
• Generalized: both
cerebral hemispheres
• Partial: one cerebral
hemisphere (localized)
Edward P. Sloan, MD, MPH
Seizures
Generalized Seizures:
• Convulsive: tonic-clonic
• Non-convulsive:
absence
Edward P. Sloan, MD, MPH
Seizures
Generalized Seizures:
• Primary generalized: starts as
tonic-clonic sz
• Secondarily generalized:
tonic-clonic sz develops from
a non-convulsive partial sz, ie
aura (common)
Edward P. Sloan, MD, MPH
Seizures
Partial Seizures:
• Simple partial: no
impaired consciousness
• Complex partial:
impaired consciousness
Edward P. Sloan, MD, MPH
Seizures
Specific Seizure Types:
• Absence: Petit mal
• Partial: Jacksonian, focal
motor
• Complex partial: temporal
lobe, psychomotor
Edward P. Sloan, MD, MPH
Seizures
Recurrent Seizure Risk
• 51% recurrence risk
• 75% of recurrent sz occur
within 2 years of first sz
• Only a small % of pts will
seize within 24 h
• Partial sz, CNS abnormality
Edward P. Sloan, MD, MPH
Status Epilepticus:
• Sz > 5- 10 minutes
• Two sz without a lucid
interval (Assumes
ongoing sz during coma)
Edward P. Sloan, MD, MPH
Status Epilepticus
SE Epidemiology:
• Risk of SE: greatest at age
extremes (pediatric and
geriatric populations)
• SE: occurs in setting of new
onset sz, acute insult, or
chronic epilepsy
• 150,000 cases per year
Edward P. Sloan, MD, MPH
Status Epilepticus
SE Classification:
• GCSE: (Generalized
convulsive SE) with tonicclonic motor activity
• Non-GCSE
Edward P. Sloan, MD, MPH
Status Epilepticus
Two Non-GCSE Types:
• Non-convulsive SE
• Absence SE
• Complex-partial SE
• Subtle SE
• Late generalized convulsive SE
• Coma, persistent ictal
discharge
• Very grave prognosis
Edward P. Sloan, MD, MPH
Seizures/SE
Systemic Effects:
• Hypertension (early)
• Hypotension (later)
• 49% will have temp > 100.5 F°
• Lactic acidosis
• Hypercarbia
Edward P. Sloan, MD, MPH
Seizures/SE
Pathophysiology:
• Glutamate toxic mediator
• Necrosis occurs even if
systemic problems are
treated (HTN, fever,
rhabdomyolysis, resp
acidosis, hypoxia)
Edward P. Sloan, MD, MPH
Seizures/SE
Pathophysiology:
• Early compensation for
increased CNS metabolic
needs
• Decompensation at 40-60
minutes, associated with
tissue necrosis
Edward P. Sloan, MD, MPH
Seizures/SE
AMS in Seizures:
• Mental status should
improve by 20-40 minutes
• If pt comatose, subtle SE is
possible: EEG
• Up to 20% of pts in coma
are still in SE
Edward P. Sloan, MD, MPH
Seizures/SE
Ongoing SE Effects:
• Over 40-60 min, loss of
metabolic compensation
• With ongoing SE, systemic
BP & CBF drop
Edward P. Sloan, MD, MPH
Status Epilepticus
SE Mortality:
• SE mortality > 30% when sz
longer than 60 minutes
• Underlying sz etiology
contributes to mortality
Edward P. Sloan, MD, MPH
Status Epilepticus
Subtle SE:
• Mortality exceeds 50%
• Often after hypoxic insult
• Coma
• Limited motor activity
• Stop the sz, EEG confirm
Edward P. Sloan, MD, MPH
Status Epilepticus
Refractory SE:
• No response to first-line
drugs (Benzos, phenytoins)
• Significant CNS disorders
• 6-9% of all SE cases
• 20-30% mortality
Edward P. Sloan, MD, MPH
General ED Management:
• ABCs
• Glucose, narcan, thiamine
• Rapid sequential use of
AEDs
• Directed evaluation
Edward P. Sloan, MD, MPH
ED Management
Lab Evaluation:
• Key lab abnormality:
hypoglycemia, in up to 2%
• Directed labs, including
anti-epileptic drug levels
Edward P. Sloan, MD, MPH
ED Management
Lumbar Puncture:
• Fever and CSF pleocytosis
can occur in SE without
meningitis
• Use clinical criteria to
determine LP need
• AMS, immunocompromise,
meningismus
Edward P. Sloan, MD, MPH
ED Management
CT Neuroimaging:
• Req’d in new-onset sz
• Useful with focal sz, change
in sz type or frequency, comorbidity
• Non-contrast unless mass
lesion suspected
Edward P. Sloan, MD, MPH
New Onset Sz in Pregnancy
• 32 year old Hispanic female
• 23 weeks pregnant
• G3P2 two live births, no
complications
• New onset seizure at 530 am in bed
• Generalized tonic-clonic seizure
• Brief, self-limited, no Rx required
• EMS to the ED, no seizure
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
Focal hemorrhage
Edward P. Sloan, MD, MPH
New Onset Sz in Pregnancy
– Tertiary center diagnosis: cavernoma
– Started on an anti-epileptic drug
– No immediate need for operative
intervention
– Will follow as pregnancy progresses
Edward P. Sloan, MD, MPH
ED Management
MRI Neuroimaging:
• Useful with refractory sz
• Complements plain CT
• Can be done as outpatient
Edward P. Sloan, MD, MPH
ED Management
EEG Monitoring:
• Use to rule out subtle SE
• Two-lead EEG in ED, within
120 minutes
• In RSI, prolonged coma,
propofol or pentobarbital
induced coma
Edward P. Sloan, MD, MPH
ED Management
AED loading:
• Repeated seizures, high-risk
population, significant SE
risk
• No need to determine level in
ED after loading
• Oral loading in low risk pts
Edward P. Sloan, MD, MPH
ED Management
SE Rx Timeline:
• 0-30 min: ABCs, benzos
• 30-60 min: Phenytoins
• 60-90 min: Levetiracetam,
phenobarbital, valproate
• 90-120 min: Midazolam, propofol
CT, EEG, ICU/OR
Edward P. Sloan, MD, MPH
Hospital Admission:
• Repeated sz, high-risk pt,
significant SE risk
• Esp if no AED loading
• New-onset seizure:
admission is preferred
(complete w/u, observe)
Edward P. Sloan, MD, MPH
ED Discharge:
• Follow-up & EEG needed,
esp if no AED prescribed
• Driving documentation is
critical. Know state law.
Edward P. Sloan, MD, MPH
ED Anti-epileptic
Drug (AED) Use
Edward P. Sloan, MD, MPH
Seizure Pharmacotherapy
•
•
•
•
Benzodiazepines
Phenytoins
Barbiturates
Other agents
–levetiracetam
–propofol
–valproate
Edward P. Sloan, MD, MPH
Pharmacotherapy
Clinical Setting:
• Three seizure settings
• Self-limited seizure, load req’d
• Flurry of seizures, at-risk for SE
• Status epilepticus
• Provides framework for
discussion
Edward P. Sloan, MD, MPH
Pharmacotherapy
General AED Concepts:
• Most drugs are at least 80%
effective in Rx seizures, SE
• Have AEDs available in ED
• Use full mg/kg doses
• Maximize infusion rates in SE
Edward P. Sloan, MD, MPH
Pharmacotherapy
Benzodiazepines:
• GABA inhibition
• Diazepam: short acting, limited
AMS and protection (intubation
more common)
• Lorazepam: prolonged AMS and
protection
• Pediatric sz: IV lorazepam limits
respiratory compromise
Edward P. Sloan, MD, MPH
Pharmacotherapy
Rectal Diazepam:
• Diazepam rectal gel prepackaged for rapid use
• Dose 0.5 mg/kg, less
respiratory depression seen
than with IV use
Edward P. Sloan, MD, MPH
Pharmacotherapy
Phenytoin:
• Stabilize memb Na+ channels,
regulate Ca+ + channels
• For generalized sz, and SE
• Constant infusion over IVP
• Use pump to prevent comp
• Therapeutic at 10-20 µg/mL
Edward P. Sloan, MD, MPH
Pharmacotherapy
Oral Phenytoin:
• 18mg/kg oral load
• 64% reach 10mg/mL levels by
8 hrs (therapeutic)
• Delayed absorption due to
large loading, or drug prep
Edward P. Sloan, MD, MPH
Pharmacotherapy
Fosphenytoin:
• Pro-drug, dose same as pht
• Infuse at 150 mg/min in SE
• Can be given IM up to 20cc
• Level 10-20 µg/mL
• Delayed level: 2h IV, 4 h IM
Edward P. Sloan, MD, MPH
Adverse Events Following
IV CEREBYX® or IV Phenytoin
100
CEREBYX at 150 mg PE/min (n=90)
IV Phenytoin at 50 mg/min (n=22)
59.1
60
40
Pruritis unique to fospht
48.9
44.4
31.1
27.3
27.3
20.0
20
18.2
11.1
ax
ia
ce
en
si
on
H
yp
ot
H
ea
Pa
re
st
he
s
ia
iti
s
Pr
ur
ne
ss
D
iz
zi
us
gm
N
ys
ta
da
ch
e
0.0
0
7.7
4.5
le
n
2.2
m
no
4.4
So
4.5
At
Subjects (%)
80
Refer to full Prescribing Information for the full adverse events incidence.
Cerebyx® (fosphenytoin sodium injection) [package insert]. Morris Plains, NJ: WarnerLambert; 2002.
9.1
Pharmacotherapy
Fosphenytoin:
• Cost-effective in 6 settings
–Rapid infusion in “at-risk pts”
–Rapid infusion in SE
–High-risk IV access
–No IV access (IM)
–No cardiac monitoring (IM)
–Poor patient compliance
Edward P. Sloan, MD, MPH
Fosphenytoin
Rapid Infusion in “At-risk” Pts:
•
•
•
•
•
Infuse at 100-150 mg/min
Load in 10-20 minutes
Therapeutic after diazepam
Limits lorazepam use
Lowers monitoring need
Edward P. Sloan, MD, MPH
Fosphenytoin
Rapid Infusion in SE:
•
•
•
•
•
Infuse at 150 mg/min in SE
One gram infusion in 7 min
Full 20 mg/kg load in 10 min
30 mg/kg load in 15 min
Fos resuscitation, next AED
Edward P. Sloan, MD, MPH
Mean Plasma-Free Phenytoin
Concentration (g/mL)
CEREBYX® and IV Phenytoin:
Comparable Pharmacokinetic Profiles
3
N = 12
2
Similar time to therapeutic
free phenytoin level
1
CEREBYX at 150 mg PE/min
IV Phenytoin at 50 mg/min
0
0
30
60
90
Time After Start of Infusion (min)
Cerebyx® (fosphenytoin sodium injection) [package insert]. Morris Plains, NJ: WarnerLambert; 2002.
Always consult full Prescribing Information in package insert.
120
ED Management
SE Rx Timeline:
0-30 min: ABCs, benzos
• 30-60 min: Phenytoins
• 60-90 min: Levetiracetam,
phenobarbital, valproate
• 90-120 min: Midazolam, propofol
CT, EEG, ICU/OR
•
Edward P. Sloan, MD, MPH
Fosphenytoin
High-risk IV Access
•
•
•
•
Murphy’s Law
Extravasations will occur
Long-term complications go
undetected by ED physicians
Consider your preferences
Edward P. Sloan, MD, MPH
Fosphenytoin
No IV Access
• IVDA in lock-up, prevent SE
• Must achieve adequate level
• Avoid ED problems
• ED nurse time, agitation
• Adverse exposure risk
• Prolonged ED throughput time
Edward P. Sloan, MD, MPH
Fosphenytoin
No IV Access
• Out of hospital setting
• Protocol in EMS setting
• Long transports in rural EMS
• Specialty care providers
• Nursing homes
• Private MD offices
Edward P. Sloan, MD, MPH
Pain Scores at Injection Site
Following IM Administration of
CEREBYX® or Saline
None
Subjects (%)
100
Mild
Moderate
Severe
95.8
87.5
83.3
54.2
50
12.5
25.0
16.7
4.2
16.7
4.2
0
Saline
CEREBYX
Saline
(10 mg PE/kg)
Immediately
Post-Injection
CEREBYX
(10 mg PE/kg)
1-Hour
Follow-up
IM fos pain similar to IM saline
Adapted with permission from Pryor FM et al. Epilepsia. 2001;42:245-250.
Always consult full Prescribing Information in package insert.
IM CEREBYX® Administered
at a Single and Multiple Sites
60
100
Patients (%)
50
Single Sites
Multiple Sites
14 pts, 15+cc IM injection
(N = 11)
40
(N = 11) (N = 12)
(N = 13)
30
20
(N = 3)
(N = 4)
10
(N = 3)
(N = 3)
0
≤10
>10-15
>15-20
Volumes Administered (mL)
Ramsay RE et al. Epilepsy Res. 1997;28:181-187.
Always consult full Prescribing Information in package insert.
>20
Fosphenytoin
No Cardiac Monitoring
• ED overcrowding
• High acuity, stretched resources
• Utilize IM loading
• No need for monitoring
• Less risk of hypotension
• No unplanned rapid infusion
• More disposition options
Edward P. Sloan, MD, MPH
Fosphenytoin
Poor Patient Compliance
• Pt refuses to stay for infusion
• About to enter high risk setting
• Utilize IM loading
• Rapidly therapeutic
• Half load IM, half PO
• Reduced SE risk
• Rapid dispo, not AMA
Edward P. Sloan, MD, MPH
Fosphenytoin
Use in Elderly Patients
•
•
•
•
Caution with hypotension when
rapidly infused
CVA neuroprotection study
Related to phenytoin moiety
Rate related, slow infusion
Edward P. Sloan, MD, MPH
Fosphenytoin
Use in Pediatric Patients
•
•
•
•
•
Used in infants and children
Reasonable to use in all ages
Safety not an issue
IM and IV use both possible
Neonate indication and use: in
consultation with peds neurology
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Levetiracetam:
• Second generation AED
• Oral and IV bioequivalent
• Adjunct therapy
• No therapeutic level defined
• 1500 to 3000 mg infusion
• Few adverse effects
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Phenobarbital:
• GABA-inhib, effective SE Rx
• Infuse up to 50 mg/min
• 20-30 mg/kg, 10 mg/kg doses
• Therapeutic > 40 µg/mL
• Respiratory depression
• Hypotension
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Valproate:
•
•
•
•
•
•
Likely GABA mechanism
Useful in peds, possibly SE
Rate up to 300 mg/min
25-30 mg/kg, 3-6 mg/kg/min
Therapeutic > 100 µg/mL
Per mg/kg load, level up 5 µg/mL
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Lidocaine:
• Third-line, stabilizes
membrane Na + /K + pump
• Decreased neuron excitability,
refractory GCSE
• 3 mg/kg
• Not effective relative to others
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Midazolam Infusion:
• GABA mechanism
• Equal to diazepam infusion
• Greater breakthru sz rates
• Less hypotension
–vs. propofol, pentobarb
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Propofol Infusion:
• Likely GABA mechanism
• Provides burst suppression
• 2 mg/kg loading dose
• Hypotension, acidosis,
hypoventilation
• Rapid onset, easily reversed
Edward P. Sloan, MD, MPH
Pharmacotherapy
IV Pentobarbital:
• Likely GABA mechanism
• Provides burst suppression
• 5 mg/kg loading dose
• 25 mg/kg infusion rate
• ICU monitoring required
Edward P. Sloan, MD, MPH
Pharmacotherapy
ED Treatment Protocol:
• Have AEDs easily available
• Rapid sequential AED use
• Maximize infusion rate
• Maximize mg/kg dosing
• Benzos, phenytoins, other
bolus AEDs, continuous AEDs
Edward P. Sloan, MD, MPH
Pharmacotherapy
No IV Access:
• PR diazepam
• IM midazolam
• IM fosphenytoin
• Buccal, intranasal midazolam
• No IM phenytoin/phenobarbital
Edward P. Sloan, MD, MPH
ACEP Seizure/SE
Clinical Policy
Edward P. Sloan, MD, MPH
Evidence Based Guidelines
• Define the clinical question
– Focused questions best
– Outcome measure must be
determined
• Grade the strength of evidence
• Incorporate practice patterns,
available expertise, resources and
risk/benefit
Edward P. Sloan, MD, MPH
ACEP Clinical Policies
• Identify questions of clinical
importance to ED practitioners
• Analyze the quality of data
available related to disease state
• Differentiate anecdotal
experience from practice
supported by evidence
Edward P. Sloan, MD, MPH
Evidence Strength
• Strength (Class) of evidence
– I: Randomized, double blind
interventional studies for therapeutic
effectiveness; prospective cohort for
diagnostic testing or prognosis
– II: Retrospective cohorts, case control
studies, cross-sectional studies
– III: Observational reports; consensus
reports
Edward P. Sloan, MD, MPH
Recommendation Strength
• Strength of recommendations:
– A (Standard): High degree of
certainty based on Class I studies
– B (Guideline): Moderate clinical
certainty based on Class II studies
– C (Option): Inconclusive certainty
based on Class III evidence,
consensus
Edward P. Sloan, MD, MPH
Edward P. Sloan, MD, MPH
New Onset Sz: Lab Testing
What lab tests are indicated in the
otherwise healthy adult patient
with a new onset seizure who has
returned to a baseline normal
neurological status?
(Outcome measure: abnormal lab
that
changes management)
Edward P. Sloan, MD, MPH
New Onset Sz: Lab Testing
• Level B recommendations:
– Determine a serum glucose and
sodium on patients with a first time
seizure with no co-morbidities who
have returned to their baseline
– Obtain a pregnancy test in women of
child bearing age
– Perform a LP after a head CT either
in the ED or after admission on
patients who are immunocompromised
Edward P. Sloan, MD, MPH
New Onset Sz: Neuroimaging
Which new onset seizure patients
who have returned to a normal
baseline require neuroimaging
in the ED?
(Outcome measure: abnormal CT)
Edward P. Sloan, MD, MPH
New Onset Sz: Neuroimaging
• Level B recommendations:
–When feasible, perform a head
CT of the brain in the ED on
patients with a first time seizure
–Deferred outpatient
neuroimaging may be utilized
when reliable follow-up is
available
Edward P. Sloan, MD, MPH
New Onset Sz: Dispo/AED Use
Which new onset seizure patients who
have returned to normal baseline
need to be admitted to the hospital
and / or started on an AED?
(Outcome measure: short term
morbidity or mortality)
Edward P. Sloan, MD, MPH
New Onset Sz: Dispo/AED Use
• Level C recommendations:
– Patients with a normal neurological
examination can be discharged from
the ED with outpatient follow-up
– Patients with a normal neurological
examination and no co-morbidities
and no know structural brain disease
do not need to be started on an antiepileptic drug in the ED
Edward P. Sloan, MD, MPH
Sz/SE: Phenytoin Loading
What are effective phenytoin dosing
strategies for preventing seizure
recurrence in patients who present
to the ED with a sub-therapeutic
serum phenytoin level?
(Outcome measure: short term
seizure recurrence)
Edward P. Sloan, MD, MPH
Sz/SE: Phenytoin Loading
–Level C recommendation:
−Administer an intravenous or
oral loading dose of phenytoin
or intravenous or
intramuscular fosphenytoin,
and restart daily oral
maintenance dosing.
Edward P. Sloan, MD, MPH
Sz/SE SE Therapeutics
What agent(s) should be
administered to a patient in status
who continues to seize despite a
loading dose of a benzodiazepine
and a phenytoin?
(Outcome measure: cessation of
motor activity)
Edward P. Sloan, MD, MPH
Sz/SE SE Therapeutics
• Level C recommendation:
–Administer one of the following
agents intravenously: “highdose phenytoin,” phenobarbital,
valproic acid, midazolam
infusion, pentobarbital infusion,
or propofol infusion.
Edward P. Sloan, MD, MPH
Sz/SE: EEG Monitoring
When should an EEG be
performed in the ED?
Edward P. Sloan, MD, MPH
Sz/SE: EEG Monitoring
• Level C recommendation:
–Consider an emergent EEG for
patients suspected of being in nonconvulsive SE or in subtle
convulsive SE, for patients who
have received a long-acting
paralytic, or for patients who are in
a drug-induced coma.
Edward P. Sloan, MD, MPH
ACEP Summary
• Evidence based clinical policies are useful
tools in clinical decision making
• Policy does not create a “standard of care”
• Provides a foundation for clinical practice at
a national level
• The current literature does not support the
creation of any “level A” recommendations
– 2 of the 6 clinical questions have sufficient
evidence to support “level B”
recommendations
– 4 of the 6 recs are “level C”
Edward P. Sloan, MD, MPH
ED Patient Outcome
Edward P. Sloan, MD, MPH
ED Patient Management
•
•
•
•
•
•
•
•
Lorazepam 2 mg IVP x 5 over 10 minutes
Persistent facial and R shoulder activity
AMS: generalized seizure continues
Fosphenytoin 1 gram PE over 10 min
Fosphenytoin 1 gram PE over 10 min
Seizure ended, pt remained obtunded
Intubation immediately followed
Lidocaine, sux, rocuronium
Edward P. Sloan, MD, MPH
ED Diagnostic Evaluation
•
•
•
•
•
Non-contrast CT: Prior strokes, atrophy
Metabolic tests normal
Toxicology screening negative
Phenytoin level cancelled
Diagnoses:
• AMS
• Status Epilepticus
• Respiratory Failure
Edward P. Sloan, MD, MPH
Family Arrives, Pt History
•
•
•
•
•
•
•
Pt with history refractory seizures
Hx carotid artery occlusion R
Due for carotid endarterectomy
Phenobarbital & dilantin, compliant
Prior history of SE treated at UIC
No medic alert bracelet
No recent illness, trauma, EtOH
Edward P. Sloan, MD, MPH
Patient Outcome
•
•
•
•
•
EEG in ED, within 150 minutes
Neuro consultation, no subtle SE
Admit to Neuro ICU
Repeated paralytic dosing
Final disposition for carotid Rx
Edward P. Sloan, MD, MPH
Conclusions
• Effective ED seizure patient Rx is
critical to good long-term outcome
• Parenteral ED AED use can be easily
implemented for effectiveness
• Must understand principles that govern
ED AED use and priorities of those that
provide long-term epilepsy Rx
• Those principles are fortunately simple
and straightforward
Edward P. Sloan, MD, MPH
Recommendations
• Be able to identify the seizure type and
optimal patient therapies based on
etiology, demographics, and risk/benefit
• Establish seizure and SE protocol
• Understand fully the optimal use of all
parenteral and 2nd generation AEDs
• Stop the acute seizure & prevent SE
• Wisely prescribe so that follow-up
epilepsy management can be optimized
Edward P. Sloan, MD, MPH
Questions?
www.FERNE.org
[email protected]
312 413 7490
ferne_2007_stcatherine_sloan_seizures_final
7/20/2015 7:45 PM
Edward P. Sloan, MD, MPH