7698alorithm Seizure
7698alorithm Seizure
7698alorithm Seizure
1st Line treatment - IV Access 1st Line treatment - No IV Access Consider aetiology of seizure +/- management of cause:
• Drug intoxication or withdrawal (including alcohol)
Lorazepam 4mg IV bolus or Midazolam 10 mg Buccal / IM or • AED issues (poor compliance, poor absorption, recent AED changes,
Diazepam 10mg IV bolus Diazepam 10mg PR medication interactions or sub therapeutic levels)
• Infection (Sepsis / CNS infection)
MONITOR FOR 5 MINUTES - If status MONITOR FOR 5 MINUTES - If status
• Metabolic disturbance (electrolytes, glucose)
continues at 5 minutes repeat dose continues at 5 minutes repeat dose • CNS pathology (tumour, stroke, encephalitis, PRES,
neurodegenerative diseases etc.)
IV Levetiracetam 60mg/kg, maximum 4500mg - In 100ml sodium chloride 0.9% over 10 Avoid if: Behaviour or mood disorder, renal impairment (see BNF),
Levetiracetam
using brivaracetam
minutes Preferred for: Women of childbearing age, polypharmacy (relatively few
drug-drug interactions)
IV Phenytoin 20mg/kg, maximum 2000mg - Give undiluted. Rate 50mg/min or 25mg/min
for elderly or cardiac history. An in-line filter (0.22 microns) should be used. ALWAYS INFUSE
WITH ECG MONITORING. Additional information on loading see link: leedsformulary.nhs.uk Needs ECG monitoring Risk of arrhythmia.
Phenytoin
Avoid if: Known or suspected generalised / genetic epilepsy. Low BP /
IV Valproate 40mg/kg, maximum 3000mg - In 100ml sodium chloride 0.9% over 5 minutes. HR. Heart block. Porphyria. Overdose of recreational drugs. Alcohol
withdrawal.
AVOID IN WOMEN OF CHILDBEARING AGE IF POSSIBLE
Valproate Avoid if: woman of childbearing age, metabolic/mitochondrial disease
(suspected or known), liver failure, pancreatitis, use of carbapenem
Preferred for: known or suspected generalised / genetic epilepsy,. Co-
ONGOING STATUS EPILEPTICUS DESPITE 2nd LINE morbid mood disorder / migraines
THERAPY < 30 minutes
At ≥ 30 minutes
Commence additional IV AED from above list move to refractory Alternative AEDs to be considered with neurology discussion only – Lacosamide or
If no AED suitable from list call neurology registrar status algorithm Phenobarbital – See Page 3 for details
REFRACTORY STATUS EPILEPTICUS (RSE) THERAPEUTIC TARGET
Refractory Generalised seizures of >30 minutes duration despite 2 doses of benzodiazepine and at Burst suppression with no breakthrough seizures (clinical or EEG) for 24 -
48 hours
SE least 1 dose of AED.
Manage only in appropriate setting with anaesthetics / ICU input for airway support.
30+ mins These treatments are only to be delivered by clinicians experienced in their use. EARLY CONSIDERATIONS
• Consider neuroimaging
• Correct any metabolic derangement
• Female patients – Ensure pregnancy / eclampsia excluded
3rd line treatment - General Anaesthetic • Continuous EEG / bispectral index (BIS) monitoring, or regular EEGs
1) INDUCTION - Propofol, midazolam, thiopentone or ketamine • Ensure on adequate antiepileptic medication / AED level checked
2) MAINTENANCE - Continuous infusion of propofol and/or midazolam. • Ensure NOK informed and aware of treatment decisions / prognosis
3) CONTINUE AEDs - Ensure newly loaded AEDs and pre-hospital AEDs prescribed on eMEDs
Anaesthetic agent doses Considerations for agents choice
Propofol
Failure of seizure control after 1 hour (PRIS) – ECG, CK, lipid profile, renal function,
Maintenance: oedema. PRIS risk increases with dose.
Check AED levels 0.5-4mg/kg/hour
Consider anaesthetic agent bolus – Propofol or Midazolam
Consider starting additional IV AED – Discuss with neurology on-call if required Bolus: 0.2mg/kg Midazolam interacts with multiple drugs
Midazolam
including AEDS. Can accumulate in renal
Maintenance: failure and obese patients. Tachyphylaxis
0.1mg/kg/hour with prolonged use.
On-going failure of seizure control
Consider infusion with additional anaesthetic agent - see listed agents in grey Bolus: 3-5mg/Kg Very long half life. Prone to accumulation
Thiopental
Liaise with neurology team due to zero order kinetics.
Maintenance:
Liaise with pharmacist 5mg/kg/hour
Phenobarbital
Super SUPER REFRACTORY STATUS EPILEPTICUS (SRSE)
100mg) at 50-100mg/min
via pump
stem reflexes. Can suppress immune
system. Slows gut motility.
Refractory Generalised convulsive seizures 24 hours after induction with general anaesthesia. Maintenance:
Seek specialist neurology input.
SE Ensure AEDs and anaesthetic agent doses are optimised.
1-4mg/kg/hour
Ketamine
Starting maintenance: 1
Treatment options to consider: mg/kg/hour (see titration
in full guidelinetext)
Magnesium
myasthenia, muscle blocking agents.
• Neuroimaging lacosamide, IV phenobarbital. Maintenance: 1g / hour Monitor serum Mg2+ levels and deep tendon
• CSF / Serum: auto-immune • Immunomodulation (e.g. high dose to target serum level >3.5 reflexes. Slow rate if bradycardia occurs.
encephalitis antibody panel, exclude steroids, IV immunoglobulin , plasma mmol/L
occult infection exchange, rituximab)
• Toxicology screen: illicit drugs and • Neurosurgical intervention Treatment of SRSE should be guided by neuro-intensive care, neurology,
medications which can potentiate • Ketogenic diet (ICU dietitian discussion) neurophysiology and pharmacy in an MDT approach.
seizures • Hypothermia
• Consider paraneoplastic aetiology: CT- • Pyridoxine The management of SRSE does not currently have high quality
TAP, testicular ultrasound / pelvic • Electrical and magnetic brain randomised controlled trial evidence. Treatments should be reviewed
ultrasound, breast imaging stimulation strategies regularly and if considered to be ineffective they should be ceased to
minimise risk of adverse effects.
Patient IMMEDIATE MANAGEMENT AFTER STATUS EPILEPTICUS
PATIENTS WHO CLINICALLY REMAIN LOW GCS OR CONFUSED POST
STATUS DESPITE RESOLUTION OF GENERALISED SEIZURE ACTIVITY
care after Reassess - Airway / Breathing / Circulation Commonly post-ictal state – monitor for recovery
Assess GCS - If remains low consider causes (see box to right)
SE Assess for focal neurology
If slow to recover GCS, consider:
• Underlying pathology causing status (e.g. low glucose, alcoholic
Consider aetiology of seizure encephalopathy, illicit drug use, sepsis, stroke, cerebral bleed, CNS
In known epilepsy consider triggers infection )
• Benzodiazepine or AED side effect
• Non-convulsive status epilepticus (especially in elderly - discuss with
neurology +/- arrange urgent EEG )
Levetiracetam
Prescribe maintenance doses of loaded antiepileptic drugs on eMEDs Commence after 12 hours - 1000mg BD In renal impairment eGFR
(IV to PO conversion = 1:1) <50 review doses with BNF.
See table in right hand side column for dosing If dialysis patient, consult
If using phenytoin, ensure drug level prior to next dose renal pharmacist.
Phenytoin
(IV or tablet) = 90mg
Check serum albumin and serum phenytoin base (oral liquid
phenytoin before next dosing as per “LTHT solution).
CONSIDER WHERE TO MANAGE PATIENTS POST STATUS Intravenous Phenytoin for Status
Patients need to be in an environment where they can be observed easily Epilepticus in Adults guideline” - Access
via http://www.leedsformulary.nhs.uk
Discuss location with SpR / consultant in charge of patient’s care
Commence a ‘Seizure Record’ on PPM+ (under clinical documents) Commence after 12 hours – 1000mg BD Avoid in liver impairment
Valproate
(IV to PO conversion = 1:1)
Continue to monitor regularly for further seizure activity over next 24H
Lacosamide
(IV to PO conversion = 1:1) hepatic impairment –
discuss with pharmacy .
Only for use with neurology discussion
INFORM NEUROLOGY Discuss with neurology for dosing Discuss with pharmacy
Phenobarbital
Refer to neurology via Patient Pass
Patients not known to have epilepsy will need ‘First Fit Clinic’ follow up Only for use with neurology discussion