Diferencia entre revisiones de «Template:Seizure actively seizing management»

(Changed order of meds per 2016 guidelines)
(Convert to MedicationDose template — single source of truth with SMW; all dosing verified against AES 2016 and ESETT)
 
(No se muestran 24 ediciones intermedias de 11 usuarios)
Línea 1: Línea 1:
#Protect patient from injury
===Seizure Precautions===
#*If possible place patient in left lateral position to reduce risk of aspiration
*Protect patient from injury
#*Do not place bite block
**If possible, place patient in left lateral position to reduce risk of aspiration
#*Ensure clear airway after seizure stops
**Do not place bite block!
#[[Benzodiazepine]]
*Jaw thrust, a NPA and [[oxygen]] may be required
#*Initial therapy of choice<ref>Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.</ref>
*An IV line should be placed
#**[[Midazolam]] IM 10mg (>40kg), 5mg (13-40kg), or 0.2mg/kg<ref>McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582</ref>
 
#**[[Lorazepam]] IV 2mg or 0.1mg/kg
===Medications===
#**[[Diazepam]] IV 0.15-0.2mg/kg (up to 10mg)
*[[Benzodiazepine]] (Initial treatment of choice)<ref>Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.</ref>
#*Alternatives
**{{MedicationDose|drug=Midazolam|dose=10 mg (>40 kg), 5 mg (13-40 kg), or 0.2 mg/kg|route=IM|context=1st line benzodiazepine|indication=Status epilepticus|population=Adult}}<ref>McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582</ref>
#**[[Diazepam]] PR 0.2-0.5mg/kg (up to 20mg)
***May also be given IN at 0.2 mg/kg, max 10 mg
#**[[Midazolam]] PN or Buccal
***OR buccal at 0.3 mg/kg, max 10 mg
#Secondary medications
**{{MedicationDose|drug=Lorazepam|dose=0.1 mg/kg|route=IV|context=1st line benzodiazepine|indication=Status epilepticus|population=Adult|max_dose=4 mg|notes=May repeat one dose}}<ref>Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48</ref>
#*[[Fosphenytoin]] 20-30mg/kg/PE at 150mg/min
**{{MedicationDose|drug=Diazepam|dose=0.15-0.2 mg/kg|route=IV|context=1st line benzodiazepine|indication=Status epilepticus|population=Adult|max_dose=10 mg|notes=May repeat one dose; or PR 0.2-0.5 mg/kg (max 20 mg) once}}<ref>Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48</ref>
#**Contraindicated in pts w/ 2nd or 3rd degree AV block
 
#**May be given IM
*Secondary medications
#*[[Valproic acid]] IV 20-40mg/kg at 5mg/kg/min  
**ESETT trial<ref>[https://www.nejm.org/doi/10.1056/NEJMoa1905795 Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795]</ref> compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects <ref>[https://emcrit.org/pulmcrit/esett/ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?]</ref> which is [[Levetiracetam]]
#*[[Levetiracetam]] IV 60mg/kg, max 4500mg/dose
**{{MedicationDose|drug=Levetiracetam|dose=60 mg/kg|route=IV|context=2nd line antiepileptic|indication=Status epilepticus|population=Adult|max_dose=4500 mg|notes=Preferred in pregnancy; or 1500 mg oral load}} <span style="color:#008000"> ('''preferred in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#*[[Phenobarbital]] IV 20mg/kg at 50-75mg/min (be prepared to intubate)
**{{MedicationDose|drug=Phenytoin|dose=18 mg/kg at ≤50 mg/min|route=IV|context=2nd line antiepileptic|indication=Status epilepticus|population=Adult}} <span style="color:red"> ('''avoid in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#Refractory medications
**{{MedicationDose|drug=Fosphenytoin|dose=20-30 mg PE/kg at 150 mg/min|route=IV|context=2nd line antiepileptic|indication=Status epilepticus|population=Adult|notes=May also be given IM; avoid in suspected toxicology case}}
#*[[Propofol]] 2-5mg/kg, then infusion of 2-10mg/kg/hr OR
***Contraindicated in pts w/ 2nd or 3rd degree AV block
#*[[Midazolam]] 0.2mg/kg then inusion of 0.05-2mg/kg/hr OR
**{{MedicationDose|drug=Valproic acid|dose=20-40 mg/kg at 5 mg/kg/min|route=IV|context=2nd line antiepileptic|indication=Status epilepticus|population=Adult|max_dose=3000 mg}} <span style="color:red"> ('''avoid in pregnancy''')</span><ref>Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537</ref>
#*[[Ketamine]] 1.5mg/kg then 0.01-0.05mg/kg/hr
 
#*Anesthesia consult for inhaled anesthetics in OR for refractory status epilepticus<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref>
*Refractory medications
#Consider
**{{MedicationDose|drug=Propofol|dose=2-5 mg/kg load, then 30-200 mcg/kg/min|route=IV|context=Refractory status epilepticus|indication=Status epilepticus|population=Adult}}
#*Secondary causes of seizure (e.g. [[hyponatremia]], hypoglycemia, [[INH Toxicity, [[ecclampsia]])
**{{MedicationDose|drug=Midazolam|dose=0.2 mg/kg load, then 0.05-2 mg/kg/hr|route=IV drip|context=Refractory status epilepticus|indication=Status epilepticus|population=Adult}}
#*EEG to rule-out nonconvulsive status
**{{MedicationDose|drug=Ketamine|dose=0.5-3 mg/kg load, then 0.3-4 mg/kg/hr|route=IV|context=Refractory status epilepticus|indication=Status epilepticus|population=Adult}}<ref>Legriel S, Oddo M, and Brophy GM. What's new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.</ref>
#*Prophylactic intubation
**{{MedicationDose|drug=Lacosamide|dose=400 mg load over 15 min, then 200 mg q12hr|route=IV|context=Refractory status epilepticus|indication=Status epilepticus|population=Adult}}<ref>Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.</ref>
**{{MedicationDose|drug=Phenobarbital|dose=15-20 mg/kg at 50-75 mg/min|route=IV|context=Refractory status epilepticus|indication=Status epilepticus|population=Adult|notes=Then 0.5-4 mg/kg/hr drip; titrate to suppression-burst on EEG}}<ref>Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.</ref>
**Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)<ref>Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.</ref>
 
*Others
**{{MedicationDose|drug=Carbamazepine|dose=8 mg/kg single oral load|route=PO|context=Adjunct antiepileptic|indication=Status epilepticus|population=Adult}}
**{{MedicationDose|drug=Gabapentin|dose=900 mg/day (300 mg TID for 3 days)|route=PO|context=Adjunct antiepileptic|indication=Status epilepticus|population=Adult}}
**{{MedicationDose|drug=Lamotrigine|dose=6.5 mg/kg single oral load|route=PO|context=Adjunct antiepileptic|indication=Status epilepticus|population=Adult}}
 
===Other Considerations===
*Secondary causes of seizure (e.g. [[hyponatremia]], [[hypoglycemia]], [[INH toxicity]], [[ecclampsia]])
*Nonconvulsive seizures or [[status epilepticus]] - get EEG

Revisión actual - 15:50 20 mar 2026

Seizure Precautions

  • Protect patient from injury
    • If possible, place patient in left lateral position to reduce risk of aspiration
    • Do not place bite block!
  • Jaw thrust, a NPA and oxygen may be required
  • An IV line should be placed

Medications

  • Benzodiazepine (Initial treatment of choice)[1]
    • Midazolam 10 mg (>40 kg), 5 mg (13-40 kg), or 0.2 mg/kg IM[2]
      • May also be given IN at 0.2 mg/kg, max 10 mg
      • OR buccal at 0.3 mg/kg, max 10 mg
    • Lorazepam 0.1 mg/kg IV (max 4 mg) — May repeat one dose[3]
    • Diazepam 0.15-0.2 mg/kg IV (max 10 mg) — May repeat one dose; or PR 0.2-0.5 mg/kg (max 20 mg) once[4]
  • Secondary medications
    • ESETT trial[5] compared second line antiseizure medications and they all are equally efficacious. Therefore may be best to use the one with least side effects [6] which is Levetiracetam
    • Levetiracetam 60 mg/kg IV (max 4500 mg) — Preferred in pregnancy; or 1500 mg oral load (preferred in pregnancy)[7]
    • Phenytoin 18 mg/kg at ≤50 mg/min IV (avoid in pregnancy)[8]
    • Fosphenytoin 20-30 mg PE/kg at 150 mg/min IV — May also be given IM; avoid in suspected toxicology case
      • Contraindicated in pts w/ 2nd or 3rd degree AV block
    • Valproic acid 20-40 mg/kg at 5 mg/kg/min IV (max 3000 mg) (avoid in pregnancy)[9]
  • Refractory medications
    • Propofol 2-5 mg/kg load, then 30-200 mcg/kg/min IV
    • Midazolam 0.2 mg/kg load, then 0.05-2 mg/kg/hr IV drip
    • Ketamine 0.5-3 mg/kg load, then 0.3-4 mg/kg/hr IV[10]
    • Lacosamide 400 mg load over 15 min, then 200 mg q12hr IV[11]
    • Phenobarbital 15-20 mg/kg at 50-75 mg/min IV — Then 0.5-4 mg/kg/hr drip; titrate to suppression-burst on EEG[12]
    • Consider consulting anesthesia for inhaled anesthetics (potent anticonvulsants)[13]

Other Considerations

  1. ↑ Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016; 16(1):48-61.
  2. ↑ McMullan J, Sasson C, Pancioli A, Silbergleit R: Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Acad Emerg Med 2010; 17:575-582
  3. ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  4. ↑ Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. doi:10.5698/1535-7597-16.1.48
  5. ↑ Kapur J, Elm J, Chamberlain J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019;381(22):2103-2113. doi:10.1056/NEJMoa1905795
  6. ↑ PulmCrit- All 2nd line conventional anti-epileptics are equally good… or equally bad?
  7. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  8. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  9. ↑ Macri E, Greene-Chandos D. Neurological Emergencies During Pregnancy. Neurol Clin. 2021 May;39(2):649-670. doi: 10.1016/j.ncl.2021.02.008. PMID: 33896537
  10. ↑ Legriel S, Oddo M, and Brophy GM. What's new in refractory status epilepticus? Intensive Care Medicine. 2016:1-4.
  11. ↑ Legros B et al. Intravenous lacosamide in refractory seizure clusters and status epilepticus: comparison of 200 and 400 mg loading doses. Neurocrit Care. 2014 Jun;20(3):484-8.
  12. ↑ Pugin D et al. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. Critical Care 2014. DOI: 10.1186/cc13883.
  13. ↑ Mirsattari SM et al. Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Arch Neurol. 2004 Aug;61(8):1254-9.
Obtenido de «https://www.wikem.org/w/index.php?title=Template:Seizure_actively_seizing_management&oldid=386858»