Em basic- seizures


Treatment of active seizures



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Treatment of active seizures
Rule #1 *** ALL PATIENTS WITH ALTERED MENTAL STATUS ARE HYPOGLYCEMIC UNTIL PROVEN OTHERWISE ***
-If you can’t get a fingerstick blood sugar, give one amp D50
Rule #2- Patients with seizures die from hypoxia
-Apply a non-rebreather at 15 LPM, can put nasal cannula under mask for extra oxygen and for apenic oxygenation if RSI needed

-Pulse ox readings may be inaccurate in seizing patients- if patient has signs of cyanosis, perform RSI


Rule #3- Seizures are treated by benzos, benzos, and more benzos
-Start with Ativan (lorazepam)- 2-4mg IV or double dose IM

-Versed (midazolam)- 10mg IM- shown effective in RAMPART trial

-Valium (diazepam)- can be given but short half life, not favored

-Give multiple rounds of benzos in increasing doses



PEARL- If you can’t secure an IV, don’t hesitate to insert an IO, all labs except potassium will be same as labs from an IV
Differential- after first round of benzos, consider possible secondary causes of seizures
Labs- CBC, chem 10, creatinine kinase, LFTs, acetimonphen, aspirin, and ethanol levels, UA, serum or urine HCG (females), urine drug screen
EKG- hard to get while seizing, TCA overdose can cause widened QRS
Non-contrast CT head- for new onset seizures
Status Epilepticus- continuous seizures for more than 5 minutes or multiple seizures without return to baseline

-Represents a much more severe seizure


Second line medications- rule of 20s
Phenytoin (Dilantin)- 20 mg/kg IV, don’t max out at 1 gram

-Given at rate of 50 mg/min


Fosphenytoin (Cerebryx)- 20 mg/kg IV

-Preferred agent- can be loaded 3 times faster (150 mg/min)

-No harm if it extravasates like phenytoin

-Won’t precipitate in IV line when combined with benzos


Phenobarbital-20 mg/kg IV

-Will likely make the patient apenic, be prepared for RSI


Keppra (levitraceam)- 500mg IV

-Little evidence in status but can try it as part of “kitchen sink approach”

-Common outpatient medication, may be worth it to try


RSI in status

-Medications- etomidate fine, ketamine or propofol (diprivan) may be better in status- some evidence for benefit


-Paralytics- hotly debated

-Succhinylcholine- gets neuro exam back in 5-10 minutes, has downsides of hyperkalemia, malignant hyperthermia, etc.

-Rocuronium- no downsides of suxs but lose neuro exam for 30-45 minutes

-Some prefer to have neuro exam back with suxs, however in these patients will be getting stat EEG and admitting to ICU- rocuronium is ok to use as long as you continue aggressive treatment for status


Any patient in status should get a neurology consult for a stat EEG
Third line medications- versed drip, valproic acid, propofol drip- do this in consultation with neuro
Seizures from hyponatremia

-Will likely find this out when chemistry panel comes back

-Suspect this in patients who have consumed a lot of water, GHB

ingestion, history of chronic hyponatremia



3% Hypertonic saline
-Only need to increase sodium by a few points to stop seizures
-Give 2-3 mls/kg of 3% hypertonic saline (notice the 3s) through a large bore, good IV/IO in rapid sequential boluses until seizures stop (150-200 mls in 70kg adult)
-After seizures stop, stop hypertonic saline, recheck sodium level, and slowly replace sodium over next few days as an inpatient.

Contact- steve@embasic.org Twitter- @embasic



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