EBM: Seizure Management in the Emergency Department

THE CASE

The patient is a 28 year old male with a past medical history of epilepsy who presents after seizure like activity at home.  Patient arrives by EMS who state the patient has been alert and interactive.  They did not give him any medications in route, blood glucose was 105 mg/dL. Family called 911 after patient was seen with repetitive arm and leg movement bilaterally and gaze deviation while lying on the couch.  Episode occurred approximately 30 minutes ago and self-resolved after a few minutes without intervention.  Patient states he may have missed a few doses of his levetiracetam (Keppra), though cannot give more details.   He denies any recent fevers, chills, cough, congestion, nausea, vomiting, abdominal pain, trauma, or urinary symptoms.  

Vitals are heart rate 110, BP 132/78 mmHg, temperature of 37.4C, SpO2 of 95% on room air, respiration rate of 19 breaths per minute.  Physical exam shows an alert and oriented young man who is in no distress. Neurologic exam is notable only for mild delay in responses to questions, he has no focal deficits.  He has a mild abrasion with scant bleeding to the left side of his tongue.  No obvious signs of trauma, no cervical spine tenderness. Urine is present on his pants.  The remainder of his exam is unremarkable. IV access is established and the patient is placed on the cardiac monitor.

 Just after the provider leaves the exam room, the nurse calls for assistance and the patient appears to be seizing.  

What should the provider do?

 

CLINICAL QUESTIONS

1.   What are the first line steps to managing seizures?

This patient has now become unstable and unstable patients require providers to quickly assess and address issues with the ABC’s – Airway, Breathing, and Circulation.  The patient’s airway can be supported using a simple posterior head tilt assuming no cervical spine injury suspected.  A jaw thrust can also open the airway.  Other adjuncts include nasopharyngeal tube or an oral airway if the mouth can be opened.  Supplemental oxygen delivered via nasal cannula or other method may be needed if the patient becomes hypoxic.  Breathing can be supported with a bag-valve mask and a blood pressure should be checked to assess circulation.  If hypoglycemia is high on the differential, a repeat finger stick blood glucose may be indicated.  




2. What are the recommended first line agents to treat seizure?

Benzodiazepines are the first line treatment of on-going seizure.  Lorazepam was shown to be more effective than phenytoin and equivalent to phenobarbital or diazepam plus phenytoin by Treiman et al in 1998 [1]. Dosing is dependent on the benzodiazepine used and route of administration [2]. 

  • Lorazepam 0.1mg/kg IV, or fixed dose of 4mg

  • Diazepam 0.15mg/kg IV, max dose 10mg

  • If no IV/IO access then midazolam 0.2 mg/kg or 10mg IM/buccal/IN or 20mg rectally can be used.

3.  How long should I wait to see if the seizure responds?

 

The answer: not long.  Status epilepticus is defined as a seizure that lasts 5 minutes or longer or 2 or more seizure episodes in which the patient does not return to baseline between them [3].  Considering the time to have the initial dose of benzodiazepine drawn up and administered, the patient may be approaching status epilepticus shortly after receiving their initial dose.  Current practice is to wait about 5 minutes after the initial dose of benzodiazepines to re-dose.  Providers should evaluate if the first dose is showing any signs of treating the seizure, time of onset of the agent based on the route of administration, and clinical scenario when deciding when to re-dose.


4. When should second line agents be given and what are they?

Second line agents for treating seizures are levetiracetam, fosphenytoin, and valproic acid.  The Established Status Epilepticus Treatment Trial (ESETT) demonstrated that all medications were equally effective, though only about half of seizures resolved after 60 minutes [4].  Levetiracetam is relatively easy to administer versus the other agents so has that as an advantage. As soon as the patient meets criteria for status epilepticus, order the second line agent.  Levetiracetam has a dose of 60mg/kg for status epilepticus with a maximum of 4.5 grams [5].

5. Why is it so important to control seizure quickly?

Rhabdomyolysis, metabolic acidosis, airway compromise, cerebral hypoperfusion/ischemia, hypoglycemia are all risks of prolonged seizure activity.  GABA receptors on neurons begin to disappear from the neuron surface after about 20 minutes of seizure activity and apoptosis becomes a risk. Several medications given to stop a seizure work via the GABA receptors so if they begin to disappear, achieving seizure resolution will be harder and harder to achieve [6]. 

Figure 1: GABA receptor [7].

6.  If second line agents fail, what is the next level of intervention?

If the seizure is still occurring, then the patient needs to be intubated by rapid sequence intubation and an infusion of midazolam, propofol, or pentobarbital needs to be started.  A spot EEG can be obtained to confirm that the seizure has resolved. 

 

7.  Does Neurology need to be consulted?

Consider consulting Neurology if the patient has a seizure not due to hypoglycemia an electrolyte imbalance, or known epilepsy with medication non-adherence or if the patient was in status epilepticus. 

 

8.  What is the disposition for this patient?

If the etiology of the seizure is corrected, the patient is at their neurologic baseline, the patient was not in status epilepticus, and their risk of recurrence is judged to be low, discharge home with appropriate outpatient follow-up can be considered.  Otherwise, the patient should be admitted to the hospital for further work-up and management. 

POST BY: DR. LEONARD KELLER (R3)

FACULTY EDITING BY: DR. PAT VIJITAKULA

REFERENCES

  1. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A Comparison of Four Treatments for Generalized Convulsive Status Epilepticus. N Engl J Med. 1998; 339(12), 792–798. https://doi.org/10.1056/nejm199809173391202

  2. Drislane FW. (2022, January 10). Convulsive status epilepticus in adults: Management. UpToDate. Retrieved February 15, 2022, from https://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-management?search=seizure%20treatment&topicRef=2219&source=see_link#H2329066703

  3. Drislane FW. (2022b, January 14). Convulsive status epilepticus in adults: Classification, clinical features, and diagnosis. UpToDate. Retrieved February 15, 2022, from https://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-classification-clinical-features-and-diagnosis?search=seizure%20treatment&topicRef=96933&source=see_link#H1

  4. Kapur J, Elm J, Chamberlain JM. Barsan W, Cloyd J., Lowenstein D, et al.. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019; 381(22), 2103–2113. https://doi.org/10.1056/nejmoa1905795

  5. Levetiracetam. (n.d.). UpToDate. Retrieved February 15, 2022, from https://www.uptodate.com/contents/levetiracetam-drug-information?search=keppra&source=panel_search_result&selectedTitle=1~98&usage_type=panel&kp_tab=drug_general&display_rank=1#F187644

  6. Morgenstern J. MD. 2020, October. Status epilepticus revisited. EM:RAP. https://www.emrap.org/episode/emrap202012/status

  7. Soyka M. Treatment of Benzodiazepine Dependence. N Engl J Med. 2017; 376(12), 1147–1157. https://doi.org/10.1056/nejmra1611832

EBMLauren McCaffertyseizure, epilepsy