1. Adult Seizure and SE Patient ED Care: Crossfire Edward P. Sloan, MD, MPH, FACEP 1

2. Edward P. Sloan, MD, MPH Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL Edward P. Sloan, MD, MPH, FACEP 2

3. Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL Edward P. Sloan, MD, MPH, FACEP 3

4. 4 Housekeeping Issues Disclosures by each speaker Meeting support from UCB Pharma –Thank you Dave Riccio –IV levetiracetam, a second generation AED –May soon be an IV parenteral option in the ED Please fill out a CME form with your email Please give feedback to improve our work

5. Edward P. Sloan, MD, MPH, FACEP 5 Adult Seizures Common ED problem Seizures: 6% of EMS encounters Adult seizures: 1% of all ED visits 130 million ED visits 1.3 million seizure patient visits

6. Edward P. Sloan, MD, MPH, FACEP 6 Management Issues Address clinical concepts, dogmas Discuss clinical impact of the decisions that we make Explore how to improve adult ED seizure patient care

7. Edward P. Sloan, MD, MPH, FACEP 7 Session Format Clinical impression, belief Audience poll Input from our experts Review of the audience responses Discussion Any change in clinical perspective?

8. Edward P. Sloan, MD, MPH, FACEP 8 Initial Benzodiazepine Use It doesn’t matter which benzodiazepine is used to treat an actively seizing patient. In fact, diazepam is probably better, since it is equally efficacious and it lasts a shorter period of time, allowing for a return to a normal mental status sooner

9. Edward P. Sloan, MD, MPH, FACEP 9 Initial Benzodiazepine Use Do you agree that it does not matter which benzodiazepine is used to treat a seizing ED patient? A.Yes B.No

10. Edward P. Sloan, MD, MPH, FACEP 10 A Phenytoin Use (EtOH, Toxins) Even in settings where a phenytoin load is normally not clinically indicated (alcohol, toxin-related seizures), if a flurry of seizures or SE occurs, a phenytoin load should be provided

11. Edward P. Sloan, MD, MPH, FACEP 11 A Phenytoin Use (EtOH, Toxins) Do you agree that a phenytoin load should be given to alcohol or toxin- related seizure patients with a flurry of seizures or SE, even if a phenytoin is not normally used to treat this problem? A.Yes B.No

12. Edward P. Sloan, MD, MPH, FACEP 12 Fosphenytoin Use in SE When a phenytoin load is to provided to a patient in SE, fosphenytoin should always be used because it can be infused more quickly and with fewer adverse effects. It is recognized that the time to achieving a therapeutic free phenytoin level is comparable with either fosphenytoin or phenytoin (tens of minutes).

13. Edward P. Sloan, MD, MPH, FACEP 13 Fosphenytoin Use in SE Do you agree that when a phenytoin load is to be given to a patient in SE, fosphenytoin should always be used? A.Yes B.No

14. Edward P. Sloan, MD, MPH, FACEP 14 ED Fosphenytoin Use There are many non-SE clinical settings in which the pharmacologic properties of fosphenytoin (water soluble, no toxic diluents, extravasations not complicated, IM use possible) justify its use in ED seizure patients despite the higher acquisition cost.

15. Edward P. Sloan, MD, MPH, FACEP 15 ED Fosphenytoin Use Do you agree that there are many non- SE patients for whom ED fosphenytoin use is cost-effective because of its pharmacologic characteristics? A.Yes B.No

16. Edward P. Sloan, MD, MPH, FACEP 16 ED IV Valproate Use ED IV valproate is underutilized because of a lack of knowledge regarding its indications and clinical use, especially in patients who are taking PO valproate. –Broad indications –Infusion at 300 mg/min, no infusion AEs –Load 1 mg/kg, level increases 5 mcg/ml –Therapeutic level can exceed 125 mcg/ml

17. Edward P. Sloan, MD, MPH, FACEP 17 ED IV Valproate Use Do you agree that ED IV valproate is underutilized because of a lack of knowledge regarding its indications and clinical use, especially in patients who are taking PO valproate? A.Yes B.No

18. Edward P. Sloan, MD, MPH, FACEP 18 ED 2nd Generation AED Use Emergency Department 2 nd generation AED use is underutilized because of a lack of knowledge regarding their indications and clinical use, especially in patients who are taking oral 2 nd generation AEDs as outpatients. –Clinical indications –Class clinical characteristics –Individual drug differences

19. Edward P. Sloan, MD, MPH, FACEP 19 ED 2nd Generation AED Use Do you agree that ED 2 nd generation AED use is underutilized because of a lack of knowledge regarding their indications and clinical use, especially in patients who are taking 2 nd generation AEDs? A.Yes B.No

20. Edward P. Sloan, MD, MPH, FACEP 20 ED SE Patient Rx It doesn’t matter what drugs are used in what order in order to treat a seizing SE patients, as long as they are used quickly, in full mg/kg doses, and are ordered in parallel (the next drug is being ordered as one is being infused).

21. Edward P. Sloan, MD, MPH, FACEP 21 ED SE Patient Rx Do you agree that it doesn’t matter what drugs are used in what order in order to treat a seizing SE patients, as long as they are used quickly, in full mg/kg doses, and are ordered in parallel ? A.Yes B.No

22. Edward P. Sloan, MD, MPH, FACEP 22 ED EEG Use I know when an EEG is indicated for ED patients that I treat for seizures and SE, and I can get one in those (rare) circumstances when it is indicated in order to rule out SE.

23. Edward P. Sloan, MD, MPH, FACEP 23 ED EEG Use Do you agree that you know when an EEG is indicated for ED patients that you treat for seizures and SE, and you can get one in those (rare) circumstances when it is indicated in order to rule out SE? A.Yes B.No

24. Edward P. Sloan, MD, MPH, FACEP 24 Key Learning Points Many clinical dogmas Clinical priorities may alter practice Need to know priorities Therapies may be underutilized Clinical practice might be enhanced Need to know how to best treat ED seizure/SE patients with available Rx

25. Edward P. Sloan, MD, MPH, FACEP 25 Management Implications Know what therapies exist Make multiple drugs available Utilize them quickly, in parallel A protocol should exist Utilize EEG when necessary Improvements in patient care possible

26. Edward P. Sloan, MD, MPH, FACEP 26 CME Question Have you learned something new about treating adult seizure patients today such that you can change and improve your clinical practice? A.Yes B.No

27. Edward P. Sloan, MD, MPH, FACEP 27 CME Follow-up CME providers require follow-up to assess if your learning has indeed improved your clinical practice. Can we ask you this question via email again in the future? A.Yes B.No

28. Questions?? ferne_aaem_france_2005_sloan_adultsz_fshow.ppt 9/2/2005 2:47 AM Edward P. Sloan, MD, MPH, FACEP www.ferne.org www.ferne.org ferne@ferne.org Edward P. Sloan, MD, MPH, FACEP 312-413-7490 www.ferne.org ferne@ferne.org Edward P. Sloan, MD, MPH, FACEP edsloan@uic.edu 312-413-7490 www.ferne.org