Transcript Managing and Detecting Seizures in the ICU

Managing and Detecting
Seizures in the ICU
Special thanks to:
Katherine Nickels, MD
Assistant Professor of Neurology and Pediatrics
Mayo Clinic
Epileptic events
• Stereotyped, rhythmic, synchronous
• Not distractible or suppressible
• Eyes open
• Injury
• Incontinence
• Post-ictal confusion
• Onset during wakefulness or sleep
Generalized Status Epilepticus
• Duration:
• if szs last longer than 5-10
min, they are unlikely to stop
spontaneously
Remember…..Non-convulsive status
epilepticus in the ICU
• Simple partial, complex partial, or absence
• Can include twitching of extremity, rythmic
facial movements, etc..
• Affects the patient’s mental state, in the
absence of obvious motor manifestations
• Need high level of suspicion in sedated
intubated patient – consider EEG to confirm
Treatment
• ABCs
• Most pts breathe adequately as long as
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airway is clear
100% O2 by mask.
Intubate if evidence of respiratory
compromise
• use short-acting NM blocker so one does
not lose clinical ability to determine if
seizure is persisting
• If a long-acting paralytic is used, will need
EEG monitoring to determine if still seizing
Treatment
• R/O acute metabolic cause: hypoglycemia,
electrolyte disturbance
• The longer the status has gone on, the less
responsive it is to drug therapy
• TREAT EARLY
• Recurrent seizure after treatment with
benzodiazepine warrants consideration of an
antiepileptic drug as the next step
Further Hx and Px
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Prior sz history
Other medical illnesses
Trauma
Focal neuro signs
Signs of medical illness – infection, substance
abuse, etc
• Labs to consider: glu, lytes, calcium, gas,
renal and liver function, serum AED levels, tox
screen, blood cultures
What is the first medication to give?
Drug Treatment
• (5 minutes) Benzodiazepines (1st line):
• Lorazepam and diazepam equivalent in
efficacy and lorazepam longer acting,
therefore usually use the latter. Midazolam
also can be used.
 Dose of lorazepam: 0.1 mg/kg slow IV
push (2 mg/min)
 Dose of midazolam: 0.2 mg/kg
 Dose of diazepam: 0.5 mg/kg
• Median time to response 2-3 minutes
• Risks: respiratory depression, hypotension
Non-IV drug routes
• Rectal: diazepam, Diastat
• Buccal: diazepam, lorazepam,
midazolam
• IM: fosphenytoin, midazolam, diazepam,
lorazepam
Persistent Seizure after
Benzodiazepine
May repeat benzodiazepine while
drawing up:
Phenytoin or Fosphenytoin (2nd line)
• Fosphenytoin can be given IM without
causing tissue necrosis
• Use if IV unattainable, or
• In small child with tenuous IV site
• Fosphenytoin is ++++ more expensive
than phenytoin
• Dose 20 mg/kg of phenytoin or 20 mg/kg
PE of fosphenytoin.
• Infuse fosphenytoin 1-3 mg/kg/min
• Side effects: hypotension, arrhythmias,
tissue necrosis with phenytoin
Next steps if seizures persist
despite phenytoin
Additional antiepileptic drug
treatment
• IV Valproic acid 25 mg/kg at 5 mg/kg/min
• Unless <2 years or
• Known/suspected liver disease or
• Inborn error of metabolism, then use:
• Alternative: IV Levetiracetam 20 mg/kg at 5
mg/kg/min
Seizures continue…..
Next steps: Phenobarbital
• Can also be given as a first line drug after
benzodiazepine
• Can be given as second line drug after
Phenytoin
• Phenobarbital
• 20 mg/kg IV at rate of 50-75 mg/min
• Watch for respiratory depression
• Give slowly over about 20 minutes to
avoid side effects if necessary
Still Seizing……
Anesthesia/ICU Management
• Indications for Anaesthesia/ICU
• Severe systemic complications such as
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severe hyperthermia
Seizures lasting longer than 60 minutes
Seizures refractory to adequate doses of
benzodiazepines, phenytoin, VPA/LEV,
and phenobarbital
Anesthesia/ICU options
• All require continuous EEG monitoring,
central access, intubation
• Midazolam infusion
• Pentobarbital
• Goal is burst suppression:
• bursts <1 second in duration,
interspersed by periods of suppression
lasting at least 10 seconds. This pattern
should be present for at least 90% of the
recording.
Midazolam infusion
• Initiation:
• 0.2 mg/kg bolus followed by infusion
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at 0.12 mg/kg/hour,
Still seizing
• Give additional 0.2 mg/kg bolus and
increase to 0.24 mg/kg/hr
Maintenance
• continue increasing by 0.12 mg/kg/hr
every 10 minutes to a maximum of
1.92 mg/kg/hr to achieve burst
suppression
Seizures refractory to multi-drug
therapy and high dose midazolam
infusion:
Consider Pentobarbital Coma
IV anesthetics
• Thiopentol or pentobarb infusion
• Initiation: 5 mg/kg IV
• Maintenance: 1-3 mg/kg/hr
• Cardiac depression, agranulocytosis,
hepatic injury
• Propofol infusion:
• In children, contra-indicated due to
rhabdomyolysis, propofol infusion
syndrome, metabolic acidosis
Anesthesia/ICU options
• Isoflurane inhalation therapy
• Must be done under the guidance of
Pediatric Neurology, Pediatric Intensive
Care, Pediatric Anesthesia
• Initiation:
• 1% to 2% and adjust by 0.1% every 5–
10 mins to a goal of controlling seizure
activity.
• Any changes in administration should be
done under by Pediatric Anesthesia.
Treatment Summary
• ABCs
• Treat early for best results!
• Benzos first line, followed by phenytoin, then
VPA/LEV, then phenobarb
• ICU/Anaesthesia if prolonged >60 min,
refractory or significant systemic complication