“Simplified approach to status epilepticus” From EM Quick Hits 7 by EMC

In this post I link to and excerpt from the portion of EM Quick Hits 7 [Link is to the podcast and show notes] that discusses “Approach To Status Epilepticus” [from 0:31 to 8:35]. August, 2019 by Emergency Medicine Cases.

Here are the show notes to the above portion of the podcast:

Simplified approach to status epilepticus

Status Epilepticus: Any seizure lasting greater than five minutes including recurrent seizures that add up to five minutes without return to baseline consciousness.

Why it is bad? Prolonged seizure can lead to acidosis causing CV collapse and brain damage.

Step 1: Manage your ABCDEFG – and Don’t Ever Forget the Glucose!

  • Can consider giving glucose empirically vs a quick point of care check
  • Get IV access with stat electrolytes on VBG to rule out hyponatremia
  • Do a cursory history – think about the possibility of pre-eclampsia, which will require IV magnesium
  • Get your airway equipment ready, though often do not need to rush to manage the airway

Step 2: Benzodiazepines are first line

  • Call for two doses of benzodiazepine so you have the second dose ready to go
  • The most important determinant of stopping the seizure is time to first benzodiazepine dose – in a patient without IV access do not waste time. Give IM midazolam
  • Give ample doses: midazolam 0.15mg/kg IV or IM (about 10 mg) or lorazepam 0.1mg/kg (about 7mg)
  • If the seizure does not stop within a couple of minutes, give your second dose

Step 3: If benzos fail, propofol comes next

  •  RSI with propofol – can add ketamine and have norepinephrine on hand for potential hypotension

Step 4: Traditional anti-epileptic

  • Post intubation start your traditional antiepileptic; this can be fosphenytoin, phenytoin, or keppra.
  • Consider magnesium for pre-eclampsia, hypertonic saline for hyponatremia, and bicarbonate for TCA overdose.

Step 5: Get the patient to a place where an EEG can be placed to ensure there are no subclinical seizures

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