Chapter 19: Seizures

IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

STATUS EPILEPTICUS

Clinical Findings

A prolonged seizure lasting more than 5 minutes, or multiple seizure episodes without intervening periods of consciousness defines status epilepticus. Status epilepticus is associated with substantial morbidity and mortality. Search carefully for seizure activity in the comatose patient. Status epilepticus can be convulsive or nonconvulsive. Manifestations may be subtle (eg, deviation of head or eyes; repetitive jerking of fingers, hands, or one side of the face).

A. Perform Assessment of Airway, Breathing, and Circulation

Insert a nasopharyngeal airway. Administer 100% oxygen by nasal cannula or nonrebreathing face mask and monitor with pulse oximetry. Prepare for possible endotracheal intubation in the event that anticonvulsants fail to terminate the seizure. Listen for bilateral breath sounds and feel for symmetric pulses in all four extremities.

B. Insert an Intravenous Catheter

Obtain blood specimens for glucose, electrolytes, magnesium, and calcium determinations; hepatic and renal function tests; and complete blood count; as well as 3–4 tubes of blood for possible toxicology screen or determination of drug levels (including anticonvulsants if patient is known or suspected to be taking them). Other considerations include serial troponins, type and screen and coagulation studies.

C. Rule Out Hypoglycemia

Obtain a bedside glucose and give dextrose, 50 mL of 50% solution intravenous (IV), if the patient is hypoglycemic. Note: If malnutrition is suspected, give thiamine 100 mg IV, slowly, prior to or at the same time as glucose.

D. Pharmacologic Treatment Guideline

See Figure 19–1.

1. First-line agent

Give lorazepam, 2–4 mg (0.05–0.1 mg/kg) IV at a rate of 2 mg/min every 5 minutes to 8 mg total in adults and an additional dose of 0.05 mg/kg can be given in children. Lorazepam is currently considered the drug of choice in the hospital because of its quick onset and longer duration of action. Diazepam, 5–10 mg (0.25 mg/kg) IV can be given every 10 minutes up to 30 mg total dose in adults and 10 mg in children. If venous access cannot be obtained, diazepam can be given rectally, endotracheally, or intraosseously, or midazolam, 0.2 mg/kg, can be given intramuscularly.

2. Second-line agent

If the seizure persists after adequate doses of benzodiazepines, give fosphenytoin, a prodrug of phenytoin. Fosphenytoin dosages are ...