Differential
Diagnosis - Metabolic (hypoglycemia, hyponatremia,
hypocalcemia, hypomagnesemia, hypernatremia, hyperglycemia, hypoxia,
hypercapnia, uremia, eclampsia); Withdrawal (alcohol, benzodiazepines);
Meds/Toxins (TCAs, theophylline toxicity, cocaine, INH, CO
exposure, ASA, lithium, ETOH, high dose penicillin, non therapeutic
epileptic meds, ? toxidrome present [sympathomimetic, anticholingeric,
tricyclic]); CNS (epilepsy, neoplasm, CVA [esp. new seizures in
elderly], AVM, SAH); CNS Trauma (subdural hematoma, epidural
hematoma, cerebral contusion...); CNS Infection (meningitis, encephalitis,
abscess, toxo - AIDS, cysticercosis - Latin America); Misc.
- convulsive syncope with or without arrhythmias, DTs, CVA, TIA,
panic attack, hyperventilation, movement disorder, decerebrate posturing,
dystonia, migraine headaches, psychogenic.
Work - Up Glucose, CBC, lytes, creatinine,
BUN, calcium, magnesium, phosphage, ABG, drug levels prn, ETOH,
U/A, UDS, HCG, LP (CSF evaluation), cultures, LFTs, Head CT, EEG.
Rx ABCs - secure airway - intubate prn, IV (non dextrose), supplemental
O2, check glucose and if low give Thiamine 100 mg IV (esp. with
malnourished or alcohol abuse) and then 1 amp (50 mls) D50 IVP (peds
- 2 ml/kg of D25); Activated Charcoal - 1g/kg with suspected
overdose, Ceftriaxone - 100 mg/kg to max of 2 grams IV with ? meningitis.
Initial Medications - Lorazepam
(Ativan) - 0.1 mg/kg at a max rate of 2 mg/min IV (10 mg max), Diazepam
- 0.15-0.25 mg/kg (20 mg max) given at a max rate of 5 mg/min IV
(use rectal diazepam if IV not available: peds - 0.3-0.5 mg/kg,
adults - 0.2 mg/kg), Phenytoin - LD 18-20 mg/kg in 100 cc
NS at 50mg/min (25 mg/min with cardiac disease) max rate with complications
(hypotension, arrhythmias) - can incrase to total dose of 30 mg/kg
if initial dose ineffective, Fosphenytoin - 15/20 mg/kg IV
or IM at a max rate of 100-150 mg/min IV
Persistent Seizures - Additional
Phenytoin or Fosphenytoin to a max dose of 30 mg/kg; Phenobarbital
15-20 mg/kg at a max rate of 50-100 mg/min.
Refractory Seizure Options: Pentobarbital
5mg/kg (25 mg/min) followed by IV drip at 0.4-3.0 mg/kg/hr (need
continuous EEG monitoring); Midazolam 200 ug/kg IV bolus
followed by 2-10 ug/kg/min, Lorazepam 0.4-10 mg/hr; Consider
intubation and paralysis prn - need neuro/critical care consult
and continuous EEG monitoring.
|