7 15 2026 seizure lecture

  • related: Neurology
  • tags: #literature #neuro

Overview

  • Generalized tonic clonic seizure: bilateral, first tonic (extension of arms, head, neck), then clonic (whole body jerk)
  • Convulsing: usually refers to GTC 

Immediate Treatment

  1. Airway: put on side, add anbu bag mask to side of face with O2. NPA not helpful because of difficulty of insertion at this phase
  2. Meds: give meds once ready, don’t wait the full 5 min mark. 
    • RAMPART trial: can give either Ativan IV 4 mg (whole dose) or Versed IM 10 mg
    • Give full dose of benzo. Risk of intubation is not increased with this dose
  3. Always get POC glucose and treat if hypoglycemia. Add thiamine if worried about Wernecke
  4. Add NPA now
  5. Start EEG to look for nonconvulsive seizure if patient is unresponsive
  6. Noncontrast CT
  7. Anti epileptic: Keppra, Vimpat (avoid in low HR), Phosphenyltoin, Valproic (avoid in liver dysfunction)
    • Give full loading dose. Does not require renal dosing for loading
    • Load in general for any non metabolic seizures. Metabolic seizures are treatable conditions including alcohol withdrawal, hyponatreia, infection.
    • Post anoxic myoclonus does not always need loading

Status Epilepticus 

  • 5 or more minutes of seizure
  • Recurrent seizure without improvement in activity

In general, seizure is divided into convulsive and nonconvulsive.

Status epilepticus types: 

  • Focal status: 1 part of body
  • Tonic clonic: sometimes then becomes nonconvulsive
  • Nonconvulsive
  • Myoclonus (anoxic brain injury)
  • Psychogenic

ESETT trial: equal efficacy between different AEDs

  • General preference Keppra (cleanest drug), then phosphenyltoin (can cause CV effect with hypotension, give at slower dose over 30 min instead of 150/min, then valproic (most interaction, but for mood disorders, and does not cause sedation)

Refractory Seizures

  • Refractory to 2 medications (benzo + AED)
  • Can check free phosphenyltoin level 2 hours post meds: should target level around 2.1
  • Consider 2nd 2nd line agent
    • Lacosamide 
    • Versed gtt: load 0.1=0.2 mg/kg, then maintenance up to 1 mg/kg/hour
    • Ketamine: targets different mechanism with glutamate. Load 1-2 mg/kg, up to 1-5 mg/kg/hr
    • Avoid valproic with phenyltoin (CYP450)

Titrating down AED

  • Go down by 10% an hour of initial dose
  • Rossetti - Update on the Management of Status Epilepticus

Other things

  • SRSE: seizure after weaning AED 
  • NORSE: usually autoimmune
  • FIRES: after fever infeciton