moestown1016 Posted January 3, 2014 Share Posted January 3, 2014 I don't usually pick up seizures in the ER and want to feel more comfortable working them up and treating. Would y'all mind giving me some tips? Let's say it's not new onset. Let's also talk about how to get someone to stop having an active seizure. When / how do you bolus their med? When is a CT indicated? So besides basic labs. Drug level. Teach me! Link to comment Share on other sites More sharing options...
jdenning Posted January 3, 2014 Share Posted January 3, 2014 Patients with epilepsy are the bread and butter of my existence. I can't possibly cover everything here but this should be a start. More often than not folks who show up in the ER are frequent fliers who have longstanding issues with medication compliance. You'll want to find out what they're taking, who their neurologist is and talk to them or MD/PA or physician on call if you can. They should be able to give you good insight into what's happening - such as long hx of non compliance, transitioning one anticonvulsant to another etc. Many patients stop their meds because they can't afford them. Stress, sleep deprivation, and alcohol or other drugs are often the biggest triggers for breakthrough seizures but also look for any source of infection, dehydration, or hyponatremia as these conditions lower seizure threshold. An abscessed tooth or UTI in a developmentally delayed and/or non verbal patient can often be the cause. Starting labs should include a cbc, cmp, pregnancy test for women, and levels of whatever anticonvulsant they should be taking. Find out if they have a rescue med and whether it was given or not. Or if they have a VNS and whether the magnet was used. Seizures come in all colors shapes and sizes. If the patient has had an atonic or convulsive seizure that involves a fall you should check a HCT. In patients with any stroke risk factors you might check a HCT anyway. Otherwise find out when their last imaging was. If the event was witnessed try to get a description. Also find out if it was a typical or non typical type of event. Remember, not everything that seizes is epilepsy. Important to remember that. Lots of folks out there who have events that look like seizures but are non epileptic in nature. Most of these folks have some significant psychiatric history but may be taking an anticonvulsant anyway - particularly Depakote or lamictal. In patients who present with altered mental status don't just assume they are post ictal. Check an ammonia level particularly if they are on Depakote. Easiest meds to load IV in the ER are Dilantin and keppra - but find out what they are taking first. Best to get instructions from the neurologist on call before giving anything other than benzo. Epilepsy.com is a great website for review info. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 3, 2014 Moderator Share Posted January 3, 2014 nice summary above. also stat cbg on all szs to r/o hypoglycemia. ativan IV or intranasal(gave it tonight in fact) for seizing pts without immediate IV access works well. also can do rectal but nasal faster/easier. dilantin can be loaded PO in someone who has taken previously if they are just noncompliant and subtherapeutic. Link to comment Share on other sites More sharing options...
jdenning Posted January 3, 2014 Share Posted January 3, 2014 thought of a few more things overnight. forgot to include tox screen in the general screening labs. always a good idea to check. Patients who present in status epilepticus need IV benzo and neuro input from the get go. Status is a medical emergency Workup for a first time seizure includes all of the above +imaging +neuro referral. Neuro will then decide on imaging and EEG. Remember there are lots of patiets who have a single seizure in their lifetime and never go on to have any more. Of those patients who have a single seizure, about 30% of them will go on to have more. For patients with recurring seizures, always ask them to follow up with their neurologist. Always ask about driving and know your state law. In Oregon NO driving for a minimum of 90 days after a convulsion. The epileptologist I work with usually prefers no driving for a minimum of 90 days AND change in medication. Driving suspensions may be longer if patient drives for a living. They are usually VERY unhappy about this. Overall a really interesting group to follow Link to comment Share on other sites More sharing options...
moestown1016 Posted January 3, 2014 Author Share Posted January 3, 2014 This is great. Keep the comments coming! I do work with different personality types - you know the minimalist approach and the "do everything" approach type docs - thankfully they all don't mind questions and like to teach...I'm taking notes from these comments and plan to pick some cases up. Link to comment Share on other sites More sharing options...
skyblu Posted January 4, 2014 Share Posted January 4, 2014 For known diagnosis of seizure disorder with a seizure that is typical for them and no other factors (like trauma or unwitnessed episode), not much workup other than to exclude infections and electrolyte imbalance. CBC, BMP, UA. If symptomatic, CXR, but not always. No need for CT of brain most of the time. I document medication compliance, unusual stressors, substance abuse, etc. Urine drug screen if I'm suspicious about substances, and if they are on an anticonvulsant that can be measured I check a med level. In MA no driving for 6 months, but we do not take their license or report the seizure, so up to the patient to comply with this. I give IV Ativan 2 mg for active seizing, sometimes Dilantin. If generally well controlled and no obvious reason for seizure, I call their neurologist to see if they want to change any med dosages. Typically discharge unless other underlying issues. New onset is a different animal. Link to comment Share on other sites More sharing options...
fakingpatience Posted January 15, 2014 Share Posted January 15, 2014 nice summary above. also stat cbg on all szs to r/o hypoglycemia. ativan IV or intranasal(gave it tonight in fact) for seizing pts without immediate IV access works well. also can do rectal but nasal faster/easier. dilantin can be loaded PO in someone who has taken previously if they are just noncompliant and subtherapeutic. Have you had much success with IN medications for pediatric febrile seizures? As a paramedic I tried it once with Versed for a ~3yo febrile seizure (actually gave a much higher dose than was indicated, 10mg, but that's another issue), however it seemed that the pt was so "snotty" that it seemed like the medicine all just dripped out of his nose. Tonic clonic seizure activity didn't stop for 10 more minuets, at which point he also began hypoventilating (not sure if the versed finally took effect, or simply in his postictal state, seemed too delayed to be purely related to the versed). IN administration was actually taken out of our protocols after that, in favor of IM or PR. Aside from not having an open needle, what is the benefit to IN vs IM? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 15, 2014 Moderator Share Posted January 15, 2014 IN works a lot faster. 1 breath and it is in the central circulation vs 10-15 min for IM meds. I used IM ativan last week for a seizing adult and it worked fine. I used to do rectal valium/ativan for seizing kids but have not since we got the IN atomizers. if a kid was particularly "snotty" to b/l nares I would probably go rectal> IN. IO is an option as well but obviously more invasive. Link to comment Share on other sites More sharing options...
medic25 Posted January 15, 2014 Share Posted January 15, 2014 There is good literature to show that IM midazolam is at least as good as IV lorazepam; if you don't have IV access midazolam is a great option for a benzo to stop seizures. http://www.ncbi.nlm.nih.gov/pubmed/22335736 http://www.ncbi.nlm.nih.gov/pubmed/20624136 Link to comment Share on other sites More sharing options...
jdenning Posted January 15, 2014 Share Posted January 15, 2014 IM midazolam has been documented to be effective and we are referring patients for a study of IN midazolam Link to comment Share on other sites More sharing options...
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