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ED Seizure tips
History:
Precipitating event
Staring, Jerks
Loss of consciousness, fall
Post seizure confusion
Incontinence, Tongue bite
Injuries from fall
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Acute treatment of seizure
New onset, first seizure in life
Recurrent seizure, had prior seizure
Common Seizure medications
Acute treatment of seizure
Lorazepam 2-4 mg iv
Draw: CMP, CBC, drug level. Urine drug screen, UA
Give loading dose:
Levetiracetam (Keppra) 40-60 mg/kg, max 4500 mg iv, or
Fosphenytoin (Dilantin) 20 mg/kg, if not on Phenytoin, or
Valproate (Depacon) 20-40 mg/kg iv, if not on Valproate
Adjust loading dose if already on above
Monitor vital signs, respiratory status, suction
CT head to check for acute brain disease
Chest x ray for pneumonia
X ray if fracture suspected
NPO, Bed rest
If still has seizure, or in status
Status epilepticus
Give a loading dose of second med
if still has seizure:
Intubate
Midazolam 0.2 mg/kg iv blous, then 0.1 mg/kg/hr, titrate, or
Propofol 2 mg/kg load, then continuous infusion
Continuous EEG monitoring
CT head if not done already
LP if fever, or history suggestive of infection
Get more history: consider withdraw from alcohol, sedative
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New Onset seizure
Review above test results
Review past history: head injury, stroke, craniotomy
Review current med: that may increase chance of seizure
MRI head wo and w contrast, ck tumor, avm
EEG to define seizure type
Decide on need and choice of seizure med
Explain: Precautions and restrictions on activity, driving
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Recurrent seizure
Check for infection, UA, CHEST X RAY
Metabolic problems
Compliance with medication, by history and level
Adjust med based on compliance and drug level
Past test results seizure type, nonepileptic events
Explain: Precautions and restrictions on activity, driving
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Common Seizure Med
following available in iv and po
Levetiracetam (Keppra)
Phenytoin (Dilantin)
Valproate (Depakote)
Lacosamide (Vimpat)
Levitiracetam (Keppra)
Usual start dose 500-1000 mg bid
Excreted by urine
Pros: safe, effective for all seizure type
cons: may cause drowsiness
Phenytoin (Dilantin)
Start dose: 100 mg 3 hs, ck level in 5 days.
NOT effective for generalized onset seizure
Pros: inexpensive, effective
Cons: severe allergic reaction, nonlinear pharmakokinetics
May cause liver problem, hirsutism
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Valproaic (Depakote)
Usual start dose: Depakote ER 500 mg bid
Pros: effective for all types of seizure
Help mood disorder, prevent migraine
Cons: may casue weight gain, tremor
Rarely: liver, blood problem
Lacosamide (Vimpat)
Usual start dose: 100 mg bid
Excreted via urine
Pros: effective for all types of seizure
Less chance of drowsiness
No blood monitoring needed
Cons: expensive
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