Acute Seizure Tx

• Define Status Epilepticus

  > 5 minutes of continuous seizure activity or > 2 discrete seizures with incomplete recovery between them

  • There are 4 types (generalized convulsive, focal motor, myoclonic, tonic)
  • Generalized convulsive: impaired consciousness, bilateral tonic-clonic movement, results from failure to terminate seizures or prolonged seizure, can lead to neuronal death and injury/alteration of neuronal networks
  • Refractory: considered this after no respone to appropriate tx with benzos and ASD but seizure activity persists
• Define alcohol withdrawal seizures

  • Chronic alcohol use keeps inhibitory and excitatory tone in check and cessation causes CNS over activity hence the sx
  • Those at risk: use PAWSS (Prediction of alcohol withdrawal severity scale)
• Pathophysiology of alcohol withdrawal seizures

  Alcohol use builds a tolerance for GABA (inhibitory) and inhibits the excitatory effects of Glutamate (normally GABA would do this) so when you remove alcohol there is unopposed glutamate excitatory effects
• Minor s/sx of alcohol withdrawal

  HA, insomnia, tremulousness, mild anxiety, GI upset, anorexia, diaphoresis, palpitations
• Hallucinations in alcohol withdrawal

  Usually visual but can be tactile or auditory, develops within 12-24 hours of abstinence (ETOH does NOT have to be 0), STABLE vital signs
• Withdrawal seizures in alcohol withdrawal

  Generalized tonic-clonic convulsions, occur within 12-24 hours, associated with long history of chronic abuse, can be status epilepticus but not always, untreated will lead to delirium tremens
• Delirium tremens in alcohol withdrawal

  Hallucinations, disorientation, tachycardia, HTN, hyperthermia, agitation, diaphoresis
• Initial treatment for status epilepticus

  Goal is to STOP seizure right away

  • Assess/support: focused exam, IV access, blood draw, glucose finger stick, O2, oral suction, vital signs, consider rapid sequence intubation
  • Labs: CBC, metabolic panel, magnesium, phosphorus, liver enzymes, toxicology screen, ASD levels
  • Pharm: DOC is benzodiazepine (Ativan IV, valium IV/PR, versed IM if no IV access) b/c of their rapid onset

  1. Ativan 1st at 0.1 mg/kg w/ max rate at 2 mg/min
• Secondary treatment for status epilepticus

  • Long term: Dilantin or Depakote
  • Refractory: propofol, midazolam, phenobarbital, continuous EEG monitoring, neuro consult
  • Evaluate post ictal, may need serial neuro exams

  1. Anticonvulsant loading: dilantin, depakote, keppra
  2. Dilantin therapeutic range is 10-20, toxic level is >30, lethal levels >100
• Alcohol withdrawal treatment

  • Benzodiazepine: stimulate GABA receptors, causes decrease in neuronal activity, increase in sedation

  1. Valium, Ativan, Librium

  • Minor: supportive care, benzodiazepines (oral or IV)
  • CIWA-AR to prevent progression
  • Cirrhotic patients: Ativan (b/c shorter half life), Oxazepam (no active metabolites) which will decrease chance of oversedating a patient
  • Contraindicated: ethanol, antipsychotics, anticonvulsants, clonidine, BB, baclofen
• CIWA-AR

  • Symptom triggered therapy, IV therapy for seizures or more severe sx
  • Assessments every 10-15 mins or up to 1-2 hours