1. Seizure Management in the ED: Putting It All Together Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York

2. Patient who has seized and returned to baseline First time yes no Consider need for CBC, LFTs, Ca, Mg, PO4, drug of abuse screen alcohol level same as past events no yes check AED level assess for factors that lower seizure threshold HIV + OR Immunocompromised CT / LP Focal neurologic exam yes no CT in ED CT in ED OR Arrange CT as an outpatient Obtain electrolytes, glucose pregnancy test in woman Assess for drug use head trauma, medical illness medications, pregnancy, hypoglycemia, focal neuro exam Approach to pt who has sz and returned to baseline B CB C B B If on phenytoin and subtherapuetic load with IV, POo, IM C Discharge for outpt workup / Do not start AED C

3. Patient seizing Assess and secure the ABCs; Protect the patient from harm; Check glucose and give dextrose if <80 Perform a physical assessment; Monitor vital signs, ECG, pulse oximetry Assess need for: Antibiotics Charcoal Toxin specific therapy (eg B6, HCO3 ) Seizure stops See pathway I Seizures continue Observe and prepare for a second event Send blood for: pregnancy test, CBC, electrolytes AED levels Consider sending blood for: Mg, Ca, PO4, LFTs, ETOH, toxicology screen / levels Lorazepam, 2 mg / min to a max of 10 mg (.1 mg/kg in children) sz# stops sz continues Phenytoin 18 mg / kg at 25-50 mg / min## or Fosphenytoin 18 PE */ kg at 150 mg / min sz stopssz continues Repeat phenytoin or fosphenytoin at 1/2 the initial dose or phenobarbital 20 mg / kg at 100 mg / min sz stopssz continues Clinical pathway for status epilepticus C C C

4. Observe Prepare for another seizure Pentobarbital,** 3-5 mg / kg at 25 mg / min then drip at.5 - 3 mg / min or Midazolam 200 ug / kg bolus then 1-10 ug / kg / min or Propofol 1-2 mg / kg bolus then 2-10 mg/kg/hr Consider bedside EEG Reassess patient Intubate at any time airway or breathing is compromised Consider CT / LP # sz = seizure ## slower rates for patients with cardiovascular disease. infusion shouldbe through a large bore IV * PE = phenytoin equivalent ** watch for hypotension and treat initially with fluids; dopamine if needed AED = antiepileptic drug C C

5. Andy Jagoda, MD 1:00 AM: EMS Called for a Patient Seizing Witnesses report that patient druank 3-6 beers Patient ingested a “dot” of LSD 2 hours prior to EMS Patient asked for “help” then fell to floor seizing No history of trauma No other history available

6. Andy Jagoda, MD 1:10 AM: EMS Arrived and Called for Activation of Seizure Protocol Patient in status epilepticus BP 130/90, RR 20, P 110 Dextrostix 120 Pulse oximetry 98% saturation IV access established Diazepam 5 mg IV Q 5 min to a max of 20 mg Estimated ETA: 20 minutes

7. Andy Jagoda, MD 1:30 AM: Patient Arrived in the ED Seizing Diazepam 20 mg given in the field BP 130/90, P 110, RR 20, Rectal T 37 BS and Pulse Ox unchanged

8. Andy Jagoda, MD Physical Exam Tonic clonic activity WDWN: No evidence of immunocompromise No signs of trauma No signs of intravneous drug use Unresponsive to verbal or painful stimuli

9. Andy Jagoda, MD Physical Exam PERL: Dilated to 8 mm Gaze away from the examiner Gag intact No incontinence

10. Andy Jagoda, MD PHYSICAL EXAM THE VIDEO

11. The Results of a Diagnostic Test was Obtained

12. Andy Jagoda, MD Laboratory Tests Electrolytes: NA 143, K 4.1, CL 108, HCO 3 24 Alcohol: 120 mg/dl CPK: 240 ng/mL Tox Screen for DOA: Normal Arterial Blood Gas: pH 7.44, pO 2 110, pCO 2 36, 100% saturation

13. Andy Jagoda, MD A Dx of Psychogenic Status Epilepticus was Made Patient was given verbal suggestions that the seizures would stop if he concentrated While still “seizing” the patient began to cry for help Over 10 minutes the “seizures” slowly subsided

14. Andy Jagoda, MD Past Medical History Similar but brief event since age 10 Focal Controlled with concentration Events always occurred in association with stressful situations Emotional and physical abuse as a child Father beat him Chained to the bed Presently under stress from losing job

15. Andy Jagoda, MD The LSD “Trip” Recalled initial euphoric feeling Recalled floating sensation Followed by strong visual distortions Remembers becoming panicked that he could not control himself Remembers the seizure and all care given

16. Andy Jagoda, MD Physical Findings Suggestive of Psychogenic Seizures Out of phase movements Pelvic thrusting Head turning side to side Dilated pupils, reactive to light

17. Andy Jagoda, MD Howell et al. Pseudostatus epilepticus. Q J Med. 1989;71:507-519 40% of patients transferred in “status epilepticus” were in psychogenic status Estimated 5% TO 20% of patients referred to epilepsy centers have psychogenic seizures

18. Andy Jagoda, MD Criteria for a Conversion Disorder Alteration in physical functioning Psychological factors involved Symptoms are not unders voluntary control Symptoms are not explained by a physical disorder

19. Andy Jagoda, MD Conclusions Management of a patient with a first time seizure is based on a careful neurologic exam, and the results of a chemistry panel, head CT, and EEG Oral phenytoin loading provides “therapeutic” serum levels four hours post-load in most cases Lorazepam is the best first line treatment for seizures

20. Andy Jagoda, MD Conclusions In refractory status epilepticus, pentobarbital, midazolam, or propofol are third line agents Psychogenic seizures are characterized by out of phase motor activity, forward pelvic thrusting, voluntary eye movements, normal mental status