Etiology
- Metabolic (Hypoglycemia, hyponatremia, hypocalcemia, hypomagnesemia,
hypergylcemia, hypernatremia, hypercalcemia, hypoxia, hypercapnia,
uremia, eclampsia); Withdrawal (alcohol, benzodiazepines);
Meds/Toxins (TCAs, Theophylline toxicity, cocaine, INH, CO
exposure, Diphenhydramine, ASA, Lithium, ETOH, high dose PCN); CNS
(tumor, CVA, AVM, SAH, epilepsy, focal or partial seizure, generalized
seizure, non therapeulic antiepileptic meds); CNS Trauma (subdural
hematoma, epidural hematoma, cerebral contusion…), CNS
Infection (meningitis, encephalitis, abscess, toxo -AIDS, cysticercosis-Latin
America).
DDx - Syncope, DTs,
CVA, TIA. Panic-Anxiety Attack, Hyperventilation, Movement Disorder
Labs - chem strip,
glucose, CBC, SMAC-6, creatinine, Ca++, Mg++, drug levels. ABG,
follow up Head CT, may need spinal tap, EEG
Meds - 1. IV-NS
2. If hypoglycemic, give Thiamine 100 mg IVPB, then 1 amp
D50 IVP
3. Diazepam (Valium) 0.15 -0.25 mg/kg at max rate of 5 mg/min
IV , or consider Lorazepam (Ativan) 0.1 mg/kg at max.
rate of 2 mg/min IV. Benzodiazepine complications - respiratory
depression and hypotension. 4. Phenytoin (Dilantin)
- loading dose if actively seizing 18 mg/kg in 100 cc NS at 50 mg/min
max.; complications-hypotension, arrhythmias; maintenance -100 mg
TID; prophylaxis -15 -18 mg/kg as above; 5. Consider Phenobarbital
LD 20 mg/kg at max rate of 100 mg/min IV if seizing continues >
30 min. Be prepared for inbuation. 6. Consider Refractory Status
Epilepticus Considerations -Neuro consult, Intubation, EEG,
Pentobarbital 5 mg/kg IV then 0.5-3.0 mg/kg/hr -or - Phenobarbital
10 mg/kg q 30 min at max. rate of 100 mg/min until status ends -
or -Isoflurane - or -Propofol -or -Midazolam (bolus and drip).
Note1 - for alcohol
withdrawl seizures, anticonvulsants usually not indicated. Consider
Chlordiazepoxide 50-100 mg IM/IV q 2-4 hrs prn as initial medication
for alcohol withdrawl seizures. Drug induced seizures respond better
to benzodiazepines.
Note2 - Fosphenytoin
(Cerebyx) IV may be used instead of IV Phenytoin for control of
generalized convulsive status epilepticus. Fosphenytoin dosing is
expressed as phenytoin equivalents (PE). LD - 15-20 mg PE/kg at
100-150 mg PE/min. Maintenance -IV or PO Phenytoin, or IV Fosphenytoin
(< 5 days) 4-6 mgPE/kg/day. Less extravasation complications.
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