So what do we for the patients?
Let's say they are there,
they're having a seizure,
they're in your Emergency Department.
Check a finger stick, treat it if it's low.
You wanna make sure your patient is in a safe location,
so you wanna make sure that they're,
if they're in a stretcher,
that the side rails are up.
Potentially, that there is some blankets
or padding on those side rails.
You wanna make sure
that they're not gonna bang their head
on lots of other stuff in the Emergency Department.
Initial treatment is with a benzodiazepine.
There's a variety of medications that can be used.
Lorazepam also known as adavan, is a common one.
Midazolam also known as versed sometimes used.
Valium is sometimes used,
especially rectal valium in the pediatric patient
is a common medication that's used.
And you wanna make sure
that you're dozing those if your patient is having a seizure,
and especially in the setting of recurrent seizure.
For the most part,
many seizures will actually stop on their own
This is just for those patients
who are having persistent seizure activity.
So let's say,
you've gone ahead, you've treated a blood sugar if its low,
you've given benzodiazepine medication
and your patient is still having a seizure
or they've had a recurrent seizure
without coming back to baseline.
For those patients,
you wanna consider loading a medication called fosphenytoin
Fosphenytoin is a medication that is,
can be loaded relatively rapidly
and potentially should be preferentially given to patients
who are on phenytoin as an out-patient.
Levetiracetam is also known as keppra.
And again, if someone is on that medication
or maintained on that medication as an out-patient,
they might be a good person to load that medication with.
If you're patient's on a bunch of other stuff,
you go ahead and you can pick one or the other.
The next step in seizure management would be phenobarbital.
Phenobarbital is a very potent respiratory depressant as well,
so when you're giving this medication,
you probably wanna start getting your staff ready
for airway management,
because your patient will likely get
a very low respiratory rate
when they're getting phenobarbital.
For airway management,
after you've intubated your patient and secured their airway,
a key thing to remember here
is that in order to manage the airway,
you need to go ahead
and give the patient a paralytic in order to intubate them.
'Cause you won't be able to intubate them
without giving a paralytic
and after they're intubated and on a ventilator machine,
you wanna sedate them with propofol.
Propofol is the medication that also has anti seizure activity.
So by giving that medication,
you're adding on a further agent that can help
with your patient's seizure activity.
So for the patients who had a first time seizure,
for the most part,
those patients, providing they just have one seizure
or potentially a second,
and they come back to their baseline
and have a okay-work-up in the Emergency Department,
for the most part, those people can be discharged home
with close outpatient follow up.
So they should get a neurology appointment
or be seen by a neurologist shortly after discharge.
For the most part,
we do not initiate antiepileptic treatment or medications.
If someone has a known seizure disorder,
go ahead and check those medication levels
and you could potentially load
or [deplete 00:03:18.11] some of their medications.
The other thing that's important to mention here
is that certain states or locations
have mandatory reporting for patients who have seizures
that they not drive or operate a car.
So it's very important that you know the recommendations
or the mandatory reporting rules in your state
and that you report as appropriate
or as needed within that location.
You know, there are some special situations,
some of these we talked a little bit already,
but just go through them.
So hyponatremia can lead to seizures.
The treatment there is with generally hypertonic saline,
so a very concentrated seizure sodium solution.
You wanna be careful when you're treating hyponatremia
that you make sure
that you don't increase the sodium levels too rapidly,
but you do wanna treat them
until the seizures do in fact stop.
Hypocalcemia if it causes seizures
can be treated with calcium chloride or gluconate.
TCA overdose, tricyclic antidepressant overdose
is treated with urine alkalinization
so you wanna go ahead and give bicarbonate solution
in order to alkalinize the urine.
also treated with alkalinization of the urine
and hemodialysis for very severe cases.
Isoniazid is a medication that is used to treat tuberculosis.
When a patient overdoses on that,
pyridoxine which is a vitamin B substance,
is the treatment for seizures.
Cocaine related seizure should be treated with benzodiazepines.
And a majority of this seizures,
actually when in doubt,
going ahead and giving benzodiazepines
as your first line choice for treatment is not wrong.
if the lithium levels are severe enough
that you are having seizure related activity,
hemodialysis is your choice of treatment there.
Alcohol related seizure,
the treatment of choice is lorazepam
or some kind of benzodiazepine.
MDMAs, benzodiazepines are key.
So MDMA also known as like molly
or ecstasy are MDMA analogues.
And then eclampsia.
Eclampsia is a condition
that develops later in pregnancy for the most part
and the treatment for seizures
related to eclampsia are magnesium
and most importantly, if someone has eclampsia,
you wanted that baby to be delivered as quickly as possible
'cause that's really one of the big main treatments for eclampsia.
So disposition here,
a majority of patients can be discharged home.
Instructions for patients to avoid driving, swimming,
because if they were to have a seizure in those events,
it could potentially be very dire situations for them
and potentially others as well.
And it's important to note that some states
do have mandatory seizure reporting.
So the conclusion.
Seizures are divided into two big categories:
Generalized and Partial seizures.
There are some historical clues that can help point you
in the direction of a seizure
and rule out other etiologies
and those include oral trauma,
incontinence and confusion
or a postictal period following the event.
For someone who presents with the first time seizure,
evaluation consist of checking a glucose level,
a sodium level,
a pregnancy test in female patients,
and then also most likely a non-contrast head CT.
Treatment for persistent seizure
takes place in a step wise fashion.
So you wanna go ahead and start by checking that blood sugar,
then the benzodiazepine medications.
The next step would be loading
either a fosphenytoin or levetiracetam.
And then moving on to phenobarbital,
and eventually moving on to airway management.
Now that airway management
may need to take place in a different step
depending on if the patient develops hypoxia,
so always keeping that in mind
that the airway is always of paramount importance.
Be aware of possible airway compromise
and intubate your patient as needed.
Keep an eye on those oxygen levels.
Hypoxia is gonna be the thing
that's gonna kill the patient most acutely in these situations.