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Nonconvulsive Seizure December 16, 2014 Sample Protocol #5: Management of status epilepticus and seizures in hospitalized patients NonConvulsive Seizure December 16, 2014 Patient presents with alteration of consciousness unexplained by other etiologies AND suspicious for non convulsive seizure OR subclinical seizures noted on EEG ABCs Finger stick glucose Labs: CBC w/ Diff, CMP, Urine Drug Screen, Urine Pregnancy Test If KNOWN epilepsy, order anti- seizure medication levels IF UNKNOWN, order Magnesium and Phosphate Patient back to Seizures Yes baseline in 15-30 Terminate minutes? No Administer Yes meds. Is there IV access? No Order neurology consult Order Continuous EEG Ativan (Lorazepam): 1-2 mg IV per dose, Order Non-contrast Head Midazolam: may repeat in 5 mins, CT 0.2 mg/kg IM or IV up to 0.1 mg/kg, if up to max of 10mg not controlled after 2 If imaging reveals lesion, doses, move on order neurosurgery consult PRE No Seizures Persist? Yes Status Epilepticus Page 1 NonConvulsive Seizure December 16, 2014 First round of medication does not cease seizures: PRE Status Epilepticus Administer Meds: CHOOSE ONE Consider ICU transfer Fosphenytoin: PREFERRED Close monitoring of airway 20mg PE/kg IV initial bolus. Complete initial bolus. If unless patient meets any - Readiness to intubate clinical or electrographic seizures persist, may give add’l criteria below 5mg/kg. Rate of up to 150mg PE/min. Consider LP if clinically indicated PREGNANCY OR SEVERE Levetiracetam (Keppra): LIVER DISEASE 1,000-3,000 mg IV, at rate of 2.5 mg/kg/min IV If not already ordered: EEG or clinical exam Valproate Sodium (Depakote): Order neurology consult suggestive of MYOCLONIC 20-40 mg/kg IV, may give add’l 20mg/kg, up to 3-6 mg/ Order Continuous EEG SEIZURES kg/min Midazolam: Pt in ICU, PACU, or Initial dose of 0.2 mg/kg; administer at infusion rate of INTUBATED 2mg/min; followed by continuous infusion of 0.05mg/ kg/hr. Titrate to max tolerated dose. Consider trying another Status Seizures Persist? second line agent. Epilepticus (ONLY REPEAT ONCE) No Seizures Terminate Page 2 NonConvulsive Seizure December 16, 2014 Administer Meds: CHOOSE ONE Fosphenytoin: PREFERRED 20mg PE/kg IV initial bolus. Complete initial bolus. If unless patient meets any clinical or electrographic seizures persist, may give criteria below add’l 5mg/kg. Rate of up to 150mg PE/min. PREGNANCY OR SEVERE Levetiracetam (Keppra): LIVER DISEASE 1,000-3,000 mg IV, at rate of 2.5 mg/kg/min IV EEG or clinical exam Valproate Sodium (Depakote): suggestive of MYOCLONIC 20-40 mg/kg IV, may give add’l 20mg/kg, up to 3-6 SEIZURES mg/kg/min Midazolam: Pt in ICU, PACU, or Initial dose of 0.2 mg/kg; administer at infusion rate of INTUBATED 2mg/min; followed by continuous infusion of 0.05mg/ kg/hr. Titrate to max tolerated dose. Return to Pathway Page 3 NonConvulsive Seizure December 16, 2014 Status Epilepticus Transfer to ICU with cEEG monitoring. Consider intermittent bolus Contraindication Yes therapies of valproic acid, to intubation? leviteracitam, or fosphenytoin. No Intubate and consider need for pressors. Administer Meds: CHOOSE ONE If all other therapies fail, Treatment involves continuous infusions. Goal is to titrate to seizure suppression for consider lacosamide (Vimpat). ≥ 48 hrs. If seizures persist, goal is to titrate to burst suppression for ≥ 48 hrs. Lacosamide: 200 mg IV with maintenance of 100 mg q12. Midazolam: PREFERRED Initial dose of 0.2 mg/kg; administer at infusion rate of 2mg/min; followed by infusion of 0.05-2 mg/kg/hr Cl. Propofol: Start at 20 mcg/kg/min with 1-2 mg/kg loading dose. 30- 200 mcg/kg/min Cl. Second Choice Propofol infusion rate = 30–200 mcg/kg/min CI. Use caution when administering high doses (>80 mcg/kg/ min) for extended periods of time (i.e., >48 h) Pentobartbital: Third Choice 5-15 mg/kg, may give add’l 5-10 mg/kg: administer at infusion rate of <50 mg/min. 0.5-5 mg/kg/h Cl. Consult epileptologist. Consider Seizure Protocol MRI to be ordered by neuro or epileptlogist. Treatment management Refractory Seizures Persist? Yes with assistance from Status neuro consult and epileptologist. Consider neurosurgery consult. No Initiation of maintenance anti-seizure medication. Selection guided by epileptologist. Maintenance anti-seizure medications: Consider weaning infusion anti-seizure Phenytoin, Levetiracetam, Valproate, medications/anesthetic agents if seizure free Lacosamide, Clonazepam, Phenobarbital, 24-48 hours. Topiramate, Zonisamide, Carbamazepine, Continue cEEG for 24-48 hours once IV anti- Oxcarbazepine seizure medication/anesthetic agents infusions weaned and patient remains seizure free Transfer out of ICU per ICU transfer criteria Within 3-4 wks Follow up in Neurology Clinic with Epileptologist Page 4 NonConvulsive Seizure December 16, 2014 Administer Meds: CHOOSE ONE Treatment involves continuous infusions. Goal is to titrate to seizure suppression for ≥ 48 hrs. If seizures persist, goal is to titrate to burst suppression for ≥ 48 hrs. Midazolam: PREFERRED Initial dose of 0.2 mg/kg; administer at infusion rate of 2mg/min; followed by infusion of 0.05-2 mg/kg/hr Cl. Propofol: Start at 20 mcg/kg/min with 1-2 mg/kg loading dose. 30- 200 mcg/kg/min Cl. Second Choice Propofol infusion rate = 30–200 mcg/kg/min CI. Use caution when administering high doses (>80 mcg/kg/ min) for extended periods of time (i.e., >48 h) Pentobartbital: Third Choice 5-15 mg/kg, may give add’l 5-10 mg/kg: administer at infusion rate of <50 mg/min. 0.5-5 mg/kg/h Cl. Return to Pathway Page 5 NonConvulsive Seizure December 16, 2014 Initiation of maintenance anti-seizure medication. Selection guided by epileptologist. Consider weaning infusion anti-seizure medications/ anesthetic agents if seizure free 24-48 hours. Continue cEEG for 24-48 hours once IV anti-seizure medication/anesthetic agents infusions weaned and patient remains seizure free Return to Pathway Page 6 NonConvulsive Seizure December 16, 2014 Seizures Terminate If patient on cEEG, continue for 24-48 hours once patient remains seizure free. Return to Previous Page No Known Epilepsy? Yes Order Routine EEG Back to No if not already performed. baseline? Yes Order non-contrast head CT (within 2 hours) if not already ordered. Assess for infection Consider LP if concern for or stressors. CNS infection. Consider LP if concern for CNS infection. Consider head CT if concern for head injury, focal neurological examination, or prolonged alteration in mental status. If imaging reveals lesion, order neurosurgery consult Engage Social Work Treat underlying cause. Is risk of recurrent seizure No high? Yes Maintenance anti-seizure medications: Consider beginning Follow up in Neurology Clinic. Patient ready for Phenytoin, Levetiracetam, Valproate, or adjustment of If second line agent given, discharge once all acute Within 4 wks Phenobarbital, Topiramate, Zonisamide, maintenance anti- recommend follow-up with medical needs are met Carbamazepine, Oxcarbazepine seizure medication epileptologist. Page 7 NonConvulsive Seizure December 16, 2014 If patient on cEEG, continue for 24-48 hours once patient remains seizure free. Return to Pathway Page 8 Convulsive Seizure Where did the patient come Patient Presents with Convulsive Seizure from? Is this a convulsive Is finger stick Treat appropriately Check allergies Yes seizure? glucose abnormal? Consider Thiamine Was the patient No Do you know the given any anti- time of seizure presentation? Greater than 5 medications? No Seizures cease Minutes within 5 minutes? Assess and treat for injuries from the No seizure Yes Yes Order non-contrast head CT (within 2 hours). Order Labs: CMP, CBC, Tox Known Epilepsy? Screen, Mg, Phosphate, Back to Yes No Urine Pregnancy Test baseline? Consider LP Order AED Levels. Assess for infection or stressors. Assess and treat for injuries Did imaging from seizure Order neurosurgery reveal potential Yes consult Consider Non- surgical lesion? Convulsive Seizure No AED levels w/in No Yes normal limits? Yes Back to Baseline No Consider Labs: CMP, Order Labs: CMP, Non- CBC, Tox Screen, CBC, Tox Screen, convulsive Urine Pregnancy Urine Pregnancy pathway Test. Consider LP Test. Consider LP Order Routine Order Urgent and Imaging and Imaging Yes Yes EEG EEG Are there Engage Social No seizures on the No No Work EEG? Yes Treat underlying cause, if determined Is risk of Yes recurrent seizure No high? Maintenance AEDs: Phenytoin, Levetiracetam, Consider beginning Patient ready for Follow up in Valproate, Phenobarbital, or adjustment of discharge once all acute Within 4 wks Neurology Topiramate, Zonisamide, maintenance AED medical needs are met Clinic Carbamazepine, Oxcarbazepine Convulsive Seizure Seizure persists for >5 min Must treat acutely with 1st line anti-seizure meds Is there IV Yes No access? Lorazepam: 2-4mg IV per dose, Midazolam: may repeat in 5 mins, 0.2 mg/kg IM or IV up to 0.1 mg/kg, if up to max of 10mg not controlled after 2 doses, move on Imaging: Order non-contrast Assess for injuries head CT, (within 2 hours) if Perform neurological exam not already ordered Assess for provoking PENDING factors Seizures Persist? Yes Status Labs: CMP, CBC, Tox Screen, Epilepticus Mg, Phosphate, Urine Pregnancy Test, AED Levels, if not already ordered. No Strongly consider LP Order Imaging, labs, EEG EEG Routine: Pt back to baseline Known Epilepsy? Yes Urgent: if altered mental status greater than 30 minutes post convulsions Order AED Levels. Assess for infection, stressors, injuries. No Consider neuro consult. If imaging reveals AED levels w/in No Yes lesion, order normal limits? neurosurgery consult Consider Labs:
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